INTERPERSONALLY BASED PSYCHOTHERAPIES

PSYCHOTHERAPY any procedure that promotes the development of courage inner security and self- confidence making the person more functional - most important element is trust and communication - a form of mental exploration should be individualizedGeneral Types:a. Supportive is indicated for the client with poor insight because he has fewer resource and he is less intellectually capable. This includes guidance and counseling, advising, education, etcb. Uncovering or Insight includes exploring and bringing to consciousness the source of repressed and suppressed conflict that operate unconscious level.Forms of Psychotherapy:a. One on oneGoal: to provide supportive relationship so that the individual is less threatened, help client to function on higher level, to increase the individuals level of understanding of himselfand his environment.b. Group therapy - therapist with 10-12 clients in a groupGoal: to create sense of cohesiveness among group members to increase acceptance of the group members and to increase social interactionFocus : here and now, not the past Group members should have similar problem

REMOTIVATION Indication : repressed, long term hospitalized patients Primary Aim: To stimulate thinking Topics: Associated with the Real World, Topics should not touch the Wounded Areas of the Patients Life Steps;a. Climate of Acceptance-self introduction-Objective: to establish rapportb. Bridge of Reality-start to select topic assisted with real world-ask thought provoking questions-use visual aid to motivate responses from members-a poem may be readc. Sharing the world we live ind. Appreciation of the works of the world-discussion is geared toward occupations Related to the main Topic e. Climate of Appreciation -Summary -social amenities -next meeting arrangements

THERAPEUTIC RELATIONSHIP

Therapeutic relationship is a relationshipthat is established between ahealth care professionaland a client for the purpose of assisting the client to solve his problems

Components of a Therapeutic Relationshipa. Trust the nurse should be able to perceive and experience the feelings of the patient to be able to understand the patient develop when the trust is built in the nurse-client relationship. When the nurse exhibits the following behavior: caring, openness, objectivity, respect, interest, understanding, consistency, treatingthe client as a human being, suggesting without telling, approachability, listening, keeping promises, and honesty.Congruence occurs when words and actions match.

b. Genuine Interest this is manifested when the nurse is sincere and honest in her relationship with the patient. Consistency conveys sincerity that in turn foster the development of the patients trust. The nurse must maintain an honest and open communication. when the nurse is comfortable with himself or herself, aware ofHis or her strengths and limitations, and clearly focused, the clientPerceives a genuine person showing genuine interest self disclosure - the nurse willingness to share her own points of view in a therapeutic manner can be an indication of genuineness, this encourages the patient to become more open to the nurse in return. c. Empathy ability of the nurse to perceive the meanings and feelings of the client and to communicate that understanding to client Empathy is therapeutic but sympathy is not therapeutic because sympathy is pity. Sympathy leads the patient to develop a poor me self concept. therapeutic communication used are reflection, restatement and Clarification. d.Acceptance the nurse who did not become upset or respond negatively to aclientssoutbursts,anger, or acting out conveys acceptance tothe client. Avoiding judgments of the person, no matter what the behaviour is acceptance. e.Positive regard the nurse who appreciates the client as a unique worthwhile humanbeing can respect the client regardless of his or behavior, background, or lifestyleTherapeutic use of self By developing self awareness and beginning to understanding our attitude, we can begin to use aspects of our personality, experiences, values, feelings, intelligence, needs, coping skills, and perceptions to establish relationships with clients.Two Elements of Therapeutic Use of Self1. Self-awareness 2. Self- disclosure

Self-Awareness is the process of developing an understanding of ones own values, beliefs, thoughts, feelings, attitudes, motivations, prejudices, strengths and limitations and how these qualities affect others. Nurses must clearly understand themselves to promote their clients growth and to avoid limiting clients choices to those that nurses value. One tool that is useful in learning more about oneself is the Johari window- which creates a word portrait of a person in four areas and indicates how well that person knows himself or herself and communicates with others.Self Disclosure means revealing personal information such as biographical information and personal ideas, thoughts and feelings about oneself to clients.

JOHARIs WINDOW: portrait of a self in 4 areas.a. Open/Public Self qualities known by self and othersb. Blind/ Unaware Self qualities known only to othersc. Hidden/Private Self qualities known only to oneselfd. Area of the Unknown an empty quadrant to symbolize qualities as yet undiscovered by oneself or others

Patterns of KNOWING: Hildegard Peplau identified PRECONCEPTIONS, or ways one person expects another to behave or speak, as a road block to the information of an authenticrelationship.

Patterns of Knowing accdng to Carper (1978)i. Empirical Knowing (obtained from the science of nursing)ii. Personal Knowing (obtained from life experiences)iii. Ethical Knowing (obtained from the moral knowledge of nursing)iv. Aesthetic Knowing (obtained from the art of nursing) Types of Relationship:1. Social Relationship initiated for the purpose of friendship, socialization, companionship or accomplishment of task.2. Intimate Relationship - involves two people who are emotionally committed to each other. Include sexual or emotional intimacy as well as sharing of mutual goals.3. Therapeutic Relationship focuses on the needs, experiences, feelings, and ideas of the client only.

Therapeutic communicationTherapeutic Communication is a process in which the nurse consciously influences a client or helps the client to a better understanding through verbal or nonverbal communication. Therapeutic communication involves the use of specific strategies that encourage the patient to express feelings and ideas and that convey acceptance and respect.a. Characteristics1. Verbal >written/spoken2. Non-verbal -> posture, tone of voice, facial expressionTypes of Non-verbal communication:a. Kinesis 1.body movement 2.eye contact 3.gesturesb. Paralanguage1. voice quality2. Non-language vocalization (crying, sobbing, moaning)c. Proxemics law of space relationshipIntimate zone --- 0 to 18 inchesPersonal zone ---- 18 to 36 inchesSocial zone --------4-12 feetPublic zone --------12-25 feetd. Touch

Types of Touch (Knapp,1980)1. Functional-professional touch used to examinations or procedures (assess skin turgor)2. Social-polite touch used in greeting, such as a hand-shake and the air kisses some womenuse to greet acquaintances, or when a gentle hand guides someone in the correct direction.3. Friendship-warmth touch hug in greeting, or the back slapping some men use to greet friends and relatives4. Love-intimacy touch - tight hugs and kisses between lovers or close relatives.5. Sexual arousal touch used by lovers

e. Cultural artifacts (bless, kiss the hand as expression of being thankful, shake hands)

PHASES OF NPI or Nurse client Interaction:1. Orientation Phase begins when the nurse and client meet and ends when the client begins to identify problems to examine. Nurse establish role, the purpose of meeting and the parameters of subsequent meetings, identifies the client problem and clarifies expectations. Before meeting, reads the background materials available on the client; be familiar with any medications the client is taking; gathers necessary paper work and arranges for a quiet, private, and comfortable position. Consider his or her personal strengths and limitations Nurse begins to build trust with the client. Nurse should listen closely to the clients history, perceptions, and misconceptions Provide support and empathy of pts feelingsMajor Task: to provide mutual agreement (contract)

2. Working Phase longest and most productive phase identify perception to reality, support system and coping mechanisms. Two sub-phases :a. identification the client identifies the issues or concerns causing the problemsb. exploitation the nurse guides the client to examine feelings and responses and to develop better coping skills and a more positive image Major Task: Identification and resolution of the patients problems.Other Tasks:a. maintaining the relationshipb. gathering more datac. exploring perceptions of realityd. developing positive coping mechanismse. promoting a positive self-conceptf. encouraging verbalization of feelingsg. facilitating behavior changeh. working through resistancei. evaluating progress and redefining goals as appropriatej. providing opportunities for the client to practice new behaviorsk. promoting independence Problems: Transference when the client unconsciously transfer to the nurse feelings he or she has for significant others. Countertransference occurs when the therapist displaces onto the client attitudes or feelings from his or her past; process that can occur when the nurse responds to the client based on personal, unconsciousneeds and conflicts.

3. Termination Phase or the resolution phase (Final stage) Begins when the problems are resolved, and it ends when the relationship is ended. Evaluate the summary of progress Reinforce change and strength of the client Give rewards for cooperation Encourage about expression of feelings about termination of relationship Terminate the relationship without giving promises.

Roles of the nurse in Therapeutic Relationship 1.Teacher2.Caregiver3. Advocate ensuring privacy and dignity, promoting informed consent, preventing unnecessary examinations and procedures, accessing needed services and benefits and ensuring safety from abuse and exploitation and observant of other health care professionals.

Possible warnings or signals of abuse of the Nurse-Client Relationship (refer to Videbeck)

Therapeutic Techniques (Communication)

Technique ExampleAccepting (conveys positive regard) Yes, that must have been difficult for you.Broad openings (allows client to select the topic) is there something youd like to talk about?Acknowledge or giving recognition (acknowledging, indicating awareness) I noticed that youve fixed your bed.

Asking direct questions How does your wife feel about you hospitalization?

Clarifying (striving to explain what is vague and searching for mutual understanding) Im not sure that I understand what you are trying to say.Confronting or presenting reality (clarifying misconceptions that client may be expressing) I see no bats flying in this room.

Consensual validation (striving to explain what is vague and searching for mutual understanding) Tell me whether my understanding of it agrees with yours

Encouraging comparison (asking client to compare similarities and differences in ideas, experiences, or interpersonal relationships) Has this ever happened before?

Encouraging description (asking client to verbalize what is being perceived) How do you feel when you take you medication?

Encouraging expression What are your feelings in regards to?

Encouraging evaluation Does participating in group therapy enable youdiscuss your feelings?

Exploring (delving further into a subject, idea, experience, or relationship) Tell me more about your job. Would you describe your responsibilities?

Focusing (taking notice of a single idea or even a single word) (assisting a patient to explore specific topic)

Giving broad openings (allows client to select the topic) or Asking open-ended questions Is there something youd like to do?

Informing (giving needed facts) Ill be your nurse for today, from 7:00 until 3:00 this afternoon.

Making observations (verbalizing what is observed or perceived) You appear to be angry. / I noticed that youre trembling.Offering general leads (encourages client to continue) Go on. / You were sayingRestating (lets client know whether an expressed statement has or has not been understood) Client:I cant sleep, I stay awake all night.Nurse:You cant sleep at night, (restating)

Summarizing During the past hour, we talked about your plans forthe future, they include...

Using silence (to induce thought, pacing, acceptance)

Validating (confirming ones observation) So you mean.

Voicing doubt I find that hard to believe.

Non-Therapeutic Communication techniquesAgreeing and disagreeing (- implies that the nurse has the right to pass judgment on whether clients ideas or opinions are right or wrong) I think you did the right thing.Advice (implies that the nurse knows what is best for client and that client is incapable of any self-direction) You should.Belittling (causes client to feel insignificant or unimportant) Dont be concerned, everyone feels like that.

Challenging But how can you be president of the United States?Defending (- to defend what client has criticized implies that client has no right to express ideas, opinions, or feelings) All doctors here are simply great.

Disapproving (implies that the nurse has the right to pass judgment on the goodness or badness of clients behavior) Thats bad.

Giving approval (implies that the nurse has the right to pass judgment on the goodness or badness of clients behavior) Thats good, Im glad that

False reassurance Dont worry, everything will be all rightFocus on caregivers feeling I feel that way too.Judging Its your own mistake.

Probing (pushing for answers to issues the client does not wish to discuss causes client to feel used and valued only for what is shared with the nurse) Now tell me about this problem, you know I have to find out.Reassuring (may discourage client from further expression of feelings if client believes the feelings will only be downplayed or ridiculed I wouldnt worry about thatRejecting ( refusing to consider clients ideas or behavior) Lets not discussRequesting an explanation (asking why implies that client must defend his or her behavior or feelings) Why do you think that?Testing Do you know what kind of hospital this is?Using Denial (blocks discussion with client and avoids helping client identify and explore areas of difficulty) Client: Im nothingNurse: Of course youre something

Several nonverbal behaviors have been designed to facilitate attentive listening. S Sit squarely facing the client. O Observe an open posture. L Lean forward toward the client. E Establish eye contact. R Relax.Techniques fostering Description Offering self making self available and showing interest and concern Active listening paying close attention to verbal and non verbal communication Silenceplanned absence of verbal remarks to allow patient toThink and say more Empathy - recognizing and acknowledging patients feelings Questioning using open ended question General lead using neutral expression to encourage patient to continue talking Restating repeating the exact words of patients to remind themOf what they said, to let them know that they are heard Verbalizing the implied - rephrasing patients words to highlight An underlying message Clarification asking patient to restate, elaborate or give examplesideas or feelings

Techniques fostering Analysis and Conclusions Making observation commenting on what is seen or heard to encourage discussion Presenting reality offering a view of what is real and what is not withoutArguing with the patient Encouraging description of perceptions asking for patients views of the situations Voicing doubt expressing uncertainty about the reality Placing an event in time or sequence asking for relationships among events Encouraging comparisons asking for similarities and differences amongFeelings, behaviors and thoughts Identifying themes asking patients to identify recurrent patterns in Thoughts, feelings and behaviors Summarizing reviewing main points and conclusions

Techniques fostering Interpretation of Meaning and Importance Focusing pursuing a topic until its meaning or importance is clear Interpreting providing a view of the meaning or importance of something Encouraging evaluation asking for patients views of the meaning orimportance of something

Techniques fostering Problem Solving and Decisions Suggesting collaboration offering to help patients solve problems Encouraging goal setting - asking patient to decide of the type of change needed Giving information providing information that will help patients make better choices Encouraging consideration of options asking patient to consider the prosand cons of possible options Encouraging decisionsasking patient to make a choice among options Encouraging the formulation of plan probing for step-by-step actionsthat will be needed

Ineffective or Inappropriate Responses and Behaviors Not fully listening, not paying attention Looking too busy, ignoring the patient Seeming uncomfortable with silence, fidgeting Being opinionated, arguing with the patient Avoiding sensitive topics; changing the topic Being superficial or using clich Having a close posture; avoiding eye contact with the patient Making false promises or reassurances Giving advice or talking too much Laughing or smiling inappropriately Showing disapproval or being judgmental Belittling feelings or minimizing problems Being defensive or avoiding the patient Making flippant or sarcastic remarks Lying or being insincere

4. Goals in the one-to-one relationship* Establish rapport with the client by being empathetic, genuine, caring, and unconditionally accepting of if a the client regardless of his behavior or beliefs* Actively listen to the client to identify the issues of concern and to formulate a client-centered goal for the interaction.* Gain an in-depth understanding of the clients perception of the issue, and foster empathy in the nurse-client relationship.* Explore the clients thoughts and feelings.* Facilitate the clients expression of thought and feelings* Guide the client to develop new skills in problem-solving.* Promote the clients evaluation of solutions

INTERACTIONS WITH SELECTED BEHAVIOR:

Violent Behavior: Stay out of striking distance ( this also reduces the threat to the patient Avoid touching the patient without approval Change the topic temporarily if a patients behavior is escalating. Suggest time out for the patient in a quiet area with fewer stimuli. Avoid entering a room alone with a patient who is not in control of his or her behavior Leave temporarily if the patient is agitated and asking to be left alone. Call for staff assistance if the s losing control.

Hallucinations: The initial approach with patients to be listening or talking with voices is to Comment on their behavior: You look as if you are listening to something.What do you hear? If the patient acknowledges hearing something that the nurse cannot hear,The nurse can say, I dont hear anything, tell me what you hear. After knowing the content, focusing the hallucination is unnecessary. I know the voices are important to you, but lets talk about your loneliness****exception****

Delusions: The initial approach with respect to delusions is clarification of meanings.Who do you think is trying to hurt you? or Tell me about this poweryou think you have.

Conflicting Values: Help the patient examine the effects or outcomes of their belief on their lives relationships, and happiness.

Severe Anxiety and Incoherent Speech Patterns: Clarify the meaning of situations In severely ill and/or anxious patients, it is more effective to key intotheir feelings and underlying themes than trying to make sense on thecontent of their speech.

Manipulation: Common manipulations are a means to gain attention, sympathy, control and Dependence. Manipulation is not often recognized until it has already worked.The initial approach is to address what is happening (or has happened) Im getting the impression that you would like me to tell you whatto do. What scares you about this decision? You are experiencing a lot of emotional pain and would like to relieve itfor you. Lets talk about what you can do to relieve it. I see you asking for a lot of attention. What is it that you really want? Limit setting is useful for manipulative client. A ppower struggle with patient is useless. Helping patient to express their needs directly to othersis more productive.

Crying: Unless crying is manipulative gesture and is prolonged or unproductive,it should be allowed and even encourage, verbally and nonverbally. Bysaying, Its ok to cry or quietly offering a tissue, the nurse gives patientspermission to cry and relieve tension. Privacy should be provided. The nurseshould be as quiet as possible until the crying has ceased. The patientis then offered an opportunity to discuss the circumstance that precipatedthe tears.

Sexual Innuendos or Inappropriate Touch Patients generally stop these behaviors when asked and should be remindedthat the actions are inappropriate. If the the behavior continue, then setting limits can be stronger: I wantto talk to you but not if you continue to touch me. If you dont stop,I will have to leave and come back later.Suspiciousness Communicate clearly, simply and congruently. Misinterpretations by patients are clarified, but argument over differences in opinion are avoided. Simple rationales or explanations for rules, activities, occurences, noises,and requests are offered regularly. Patients participation is encouraged but not forced, thus avoiding an increase in their fears.

Hyperactivity Place the patient in a quiet area with minimal auditory and visualStimulation. The nurse must remain calm, speak slowly and softly,and respect patients personal space. Directions are given in kind, simple, but firm manner.

CRISIS -> Turning point in an individuals life that produces an overwhelming emotional response; individual is confronting life circumstance or stressor that cannot be managed through customary coping strategies

CrisisCaplan (1964) identified the stages of crisis:1. The person is exposed to a stressor, experiences anxiety, and tries to cope in a customary fashion2. Anxiety increases when customary coping skills are ineffective3. The person makes all possible efforts to deal with the stressor, including attempts at new methods of coping4. When coping attempts fail, the person experiences disequilibrium and significant distress.

Phases of crisis Development1. Denial- initial reaction2. Increased tension the person recognizes the presence of crisis and continues to do activities of daily living.3. Disorganized- the person is preoccupied with the crisis and is unable to do ADL4. Attempts to reorganize the individual mobilizes previous coping mechanisms.

Characteristics of crisis1. Highly individualized2. Last for 4-6 weeks3. Person affected becomes passive and submissive4. Affects a persons support system

Crisis intervention includes a variety of techniques based on the assessment of the individual in crisis, to assist in resolution or management of the stressor or circumstance. A way of entering into the life situation of an individual, family, group, or community to help them mobilize their resources and to decrease the effect of a crisis inducing stress

The primary role of the nurse in crisis intervention is to be active and directive, she has to assist the patient.

Concept of Anxiety

Defining characteristics of Anxiety A vague feeling of dread or apprehension; it is a response to external or internal stimuli that can have behavioral, emotional, cognitive, and physical symptoms. H. Peplau described the four levels of anxiety: mild, moderate, severe and panic.STRESS pressure of varying degrees a mental and physical response to stressor is a wear or tear that life causes on the body occurs when a person has difficulty dealing with life situations, problems and goals. Accdng to Hans Selye, a psychological and physical response of the body that occurs whenever we must adapt to changing conditions, whether those conditions be real or perceived.

Types of Stress:1. Distress stress due to an excess of adaptive demands placed upon us. (this is the Bad stress) it lead to bodily and mental damage.2. Eustress the optimal amount of stress which helps promote health and growth.3. Psychophysiological Stress mental upset that triggers a physiological stress response. It leads to psychosomatic illness. This is the most common type of stress and is the major factor in the onset of psychosomatic illness.

STRESSOR->According to Selye, it is a positive or negative occurrence, or any emotion requiring response.

2 Classification of Stressor:1. Maturational stressor experiences that are expected as a part of normal processes of growth and development in a given society.2. Situational stressor less predictable and specific action are taken only when the threat is eminent or the event has occurred.

Characteristics of Stress:1. It is recurring2. It is normal3. It is brought about by stressor4. It cannot be avoided

Hans Selyes STRESS ADAPTATION THEORYStress is the major cause of disease because chronic stress causes long-term chemical changes.1. Alarm Reaction impingement of stressor on individuals activates the preparation for FLIGHT or FIGHT.a. The Flight or Fight pathway is composed of three major areas:Amygdala, Hypothalamus, and Midbrain (Limbic system)b. Electrical stimulation of these areas elicits rage behavior or flight. Bilateral lesioning (destroying the three major areas can have a calming effect. Individuals experience an increase in alertness in order to focus on the immediate task or threat and to mobilize resources and defenses to concentrate on a particular stressor. Levels of Anxiety Mild to moderate Learning and Problem Solving can occur. Pathophysiology: Factor of Stress Message (nervous system) stimulate adrenal glands to secrete adrenaline and norepinephrine for fuel and organs (liver to convert glycogen stores to glucose for food ) to prepare for potential defense needs.Too much adrenaline results in a surge of blood pressure that can damage blood vessels of the heart and brain a risk factor in heart attack and stroke.The excess production of thecortisol hormonecan cause damage to cells and muscle tissues. Stress related disorders and disease from cortisol include cardiovascular conditions, stroke, gastric ulcers, and high blood sugar levels.At this stage everything is working as it should you have a stressful event, your body alarms you with a sudden jolt of hormonal changes, and you are now immediately equipped with enough energy to handle it.

2. Stage of Resistance Individuals strive to adapt to stress Increase use of coping and defense mechanisms Problem solving and learning are difficult but can be accomplished with assistance. Psychosomatic symptoms begin to develop. Level of Anxiety Moderate to severe If overwhelmed experience next stage Pathophysiology Digestive system reduces function to shunt blood to areas needed for defense. Lungs take in more air and the heart beats faster and harder so it can circulate highly nourished blood/ oxygenated blood to the muscles to defend the body by Fight, FLIGHT or freeze behaviors.

3. Stage of Exhaustion Result from the stress that last too long or it is overwhelming, or may result from the individuals total inability to cope. Anxiety Level Severe to PanicChronic stress can damage nerve cells in tissues and organs. Particularly vulnerable is the hippocampus section of the brain. Thinking and memory are likely to become impaired, with tendency toward anxiety and depression.There can also be adverse function of the autonomic nervous system that contributes to high blood pressure, heart disease, rheumatoid arthritis, and other stress related illness. Defenses are EXAGGERATED AND DYSFUNCTION and personality becomes DISORGANIZED, thinking illogical decision making ineffective. DELUSIONS AND HALLUCINATIONS can occur with sensory misperception and greatly reduced orientation to reality. Individuals may become Violent, Suicidal or may be completely IMMOBILIZED. DEATH may occur Body stresses are depleted

PROCESS OF ANXIETYStressorlAnxietylNeurochemical/Physiological ReactionlCoping Behavior(Adaptive, Palliative, Maladaptive, and Dysfunction)

COPING WITH ANXIETY

Type of CopingDescription

AdaptiveSolves the problem that is causing the anxiety, so the anxiety is decreased. The patient is objective, rational and productive.

PalliativeTemporarily decreases the anxiety but does not solve the problem, so the anxiety eventually returns. Temporary relief allows the patient to return to problem solving.

MaladaptiveUnsuccessful attempts to decrease the anxiety without attempting to solve the problem. The anxiety remains.

DysfunctionalNot successful in reducing anxiety or solving the problem. Even minimal functioning becomes difficult, and new problems begin to develop.

MALADAPTIVE RESPONSESAnxiety A subjective experience that can be detected only by the subjective behavior that result from it. Alternating individuals to prepare for self defense. A warning sign that person perceived danger, loss or threata. health or the ability to perform the functionb. self-esteem or self-respectc. self- controld. control or power over ones lifee. status or prestigef. loved onesg. freedom or independenceh. needs, goals, desires and expectationsi. resources (emotional, physical, financial, spiritual, social and cultural.

Theories of Origin/ Predisposing Factors: Psychoanalytic View Sigmund Freud (1969) identified two types of Anxiety1. Primary Anxiety the traumatic state begins in the infant as a result of sudden stimulation and trauma of birth. It is a state of tension or drive produced by external causes.2. Subsequent anxiety is the emotional conflict between two elements of the personality. This anxiety is due to the conflict between the ID and Superego. Interpersonal Views- > Sullivan (1953), believed that through the close emotional bond between the mother and the child, anxiety is first convey by the mother to the infant who responds as if the mothering person were one unit.- He also believed that anxiety in later life arises when a person perceives that he or she will be viewed unfavorably or will lose the love of a valued person.

Behavioral View Some theorist proposed that anxiety is a product of frustration caused by anything that interferes with attaining a desired goal. Anxiety may also arise through conflict that occurs when the person experiences two competing drives and may choose between them. It drives from 2 tendencies:1. Approach (fight) tendency to do something or more toward something.2. Avoidance (flight) is the opposite tendency; not to do something or not to move toward something.

LEARNING Theories: Parental influence affects how a child responds to anxiety. The parents appropriate emotional response gives the child security and helps him learn constructive way of coping on his own.

BIOLOGIC Theories Genetic Theory - First degree relatives of clients with increased anxiety have higher rates of developing anxiety. Neurochemical Theory Gamma-amino butyric acid (GABA) is the amino acid neurotransmitter believed to be dysfunctional in anxiety disorders. GABA, an inhibitory neurotransmitter= anti anxiety agent that reduces cell excitability, thus decreasing the rate of neuronal firing.= GABA reduces anxiety and Norepinephrine increases it.

LEVELS OF ANXIETY and its NURSING MANAGEMENT:1. MILD ANXIETY (Alertness Level +1) is a sensation that something is different and warrants special attention.Psychological ResponsesPhysiologic Responses

wide perceptual field sharpened senses increased MOTIVATION effective problem solving increased learning activity irritability restlessness fidgeting GI butterflies Difficulty sleeping Hypersensitivity to noise

Key Nursing Interventions:a. Recognize the anxiety by statements such as I notice you being restless today.b. Explore causes of anxiety and ways to solve problems that cause anxiety by statements such as Lets discuss ways to ..

2. MODERATE ANXIETY (Apprehension Level +2) is the disturbing feeling that something is definitely wrong.

Psychological ResponsesPhysiological Responses

Perceptual field narrowed to immediate task Selectively attentive Cannot connect thoughts or events independently Increased use of automatisms muscle tension diaphoresis pounding pulse headache dry mouth high voice pitch faster rate of speech GI upset Frequent urination

Key Nursing Interventions:a. Speak in short, simple and easy-to-understand sentencesb. Redirect client back to the topic if the client goes off on unrelated tangent.

Nursing Interventions:

Long Term Goal: helping the patient understand the cause of the anxiety and learn new ways of controlling it.

a. Education Knowledge on predisposing and precipitating stressors, coping resource and adaptive and maladaptive response. Beneficial aspects of mild levels of anxiety in motivating learning and producing growth and creativity. Treatments

b. Recognition of Anxiety Help the patient recognize anxiety by exploring underlying feelings.E.g.Are you feeling anxious today?, Are you comfortable. I noticed you have smoked 3 cigarettes since we started talking with your husband, are you feeling anxious. ------validating and relate feelings to anxiety.

Trusting relationship Nurse should be warm, responsive listeners, gives patient adequate time to respond and support patients self-expression, they will be less threatening.

c. Insight to the anxiety Precedent of anxiety What coping mechanism did the patient use Provide outlets for anxiety: crying, talking

d. Coping with threat Anxiety reduction relaxation training, desensitization Cognitive restructuring existing alternatives Helping patient cope with negative thoughts and beliefs and recognizing other viewpoints that will help them cope to more realistic conclusions (changing irrational belief to rational belief) Learning new behavior role playing, social skills training (promote relaxation response)

e. Provide anti-anxiety oral medications

3. SEVERE ANXIETY (Freefloating +3) - creates a feeling that something bad is about to happen, or feeling of an impending doom.Psychological ResponsesPhysiological Responses

- fight and flight response sets in- perceptual field reduced to one detail or scattered details- cannot complete task- Cannot solve problems or learn effectively-behavior geared toward anxiety relief and is usually ineffective- doesnt respond to redirection- feels awe, dread, or horror- cries- Ritualistic behavior- uses maladaptive coping mechanism- severe headache- nausea, vomiting, and diarrhea- Trembling- rigid stance- vertigo- pale- tachycardia- chest pain- dilated pupils and fixed vision

Nurses Goal: To lower the persons anxiety level to moderate or mild before proceeding with anyone else

Key Nursing Interventions: Remain with the client.

SEVERE TO PANIC STAGE:Nursing Interventions:1. Establish a trusting relationship open, trusting relationship Listen to patient and encouraged to discuss their feelings of anxiety, hostility, guilt and frustration. Should answer patient questions directly and offer unconditional acceptance. Nurse should remain available and respect to patients personal space. 6-foot distance in small room may create the optimum condition for openness and discussion of fears.2. Nurses self-awareness3. Protecting and assuring the patient of his or her safety Determine the amount the patient can handle her stress Do not attack patients coping mechanism Do not argue with the patient4. Modify the environment Assume a calm, quiet manner and lower environmental stimulation Limits the patient interaction with other client to minimize the contagious feelings of anxiety.5. Encourage activity6. Medication IM anti-anxiety medications

4. PANIC ANXIETY ( +4) feelings of helplessness and terrorPsychological ResponsesPhysiological Responses

- perceptual field reduced to focus on self- cannot process any environmental stimuli- distorted perceptions- Loss of rational thought- doesnt recognize potential problem- cant communicate verbally- possible delusions and hallucination- may be suicidal- may bolt and run or totally immobile and mute- dilated pupils- increased blood pressure and pulse- Flight, fight, or Freeze

Key Nursing Interventions:a. clients safety is the primary concernb. Talk in a comforting manner even though the client cannot process what the nurse is saying.c. Go to small, quiet and non stimulating environment.d. Reassure the client that it is just anxiety and that it will pass, and that he or she is in safe place.e. Remain with the client until panic recedes. (last from 5 to 30 minutes)f. Administer anxiolytics.

Nursing Intervention that could increase Anxiety:1. Pressuring the patient to change prematurely.2. Being judgmental.3. Verbally disapproving patients behavior.4. Asking the patient a direct question that brings defensiveness.

TREATMENT STRATEGIES:Cognitive Behavioral TreatmentAims:1. Increasing activity.2. Reducing unwanted behavior3. Increasing pleasure4. Enhancing social skills

Anxiety Reduction

1. Relaxation Training decrease tension and anxiety. Basic premise is that muscle tension is related to anxiety Involves rhythmic breathing.

2. Systematic Relaxation involves relaxing voluntary muscles in an orderly sequence until the body as a whole, is relaxed

Techniques: patient seated in a comfortable chair with presence of soft music or pleasant visual cues----explain how anxiety is related to muscle tension----procedure should be described----deep breathing and exhaling slowly ---tension relaxation begins.

3. MeditationComponents:A quiet environment A comfortable positionA passive attitude A word or scene to focus on

4. Biofeedback- electrodes connected to the machine are attached to the patients forehead---brain waves, muscle tensions, temp, HR and BP ----the changes are communicated with the patient by auditory or visual means

5. Systematic DesensitizationExample:Construct a hierarchy of provoking or feared situations from 1 to 10, 1 is evoking little and 10 evoking intense or severe anxiety.In vitro, or imagined, desensitization, the patient proceeds with the imagined pairing of hierarchy items with the relaxed state, progressing from the least anxiety-provoking item to the most anxiety provoking item. ..(implosion)In vivo, exposes the patient to real rather than imagined life situations(flooding)

6. Interoceptive Exposure Hierarchy is made of the specific symptoms that increase the patients anxiety.

7. Flooding patient is immediately exposed to the most anxiety-provoking stimulus instead of exposing gradually or systematically to a hierarchy of feared stimuli.Implosion imaginary event instead of a real life event.

8. Response Prevention This technique is based on the concept that repeated exposure to an anxiety-producing stimulus without the presence of the anxiety reducing response will lead to anxiety reduction because the feared consequence does not occur. Example: use of public restroom and engage in hand washing up to 20 times.

9. Eye Movement Desensitization --- Hypnosis

LEARNING NEW BEHAVIOR: Modeling strategy used to form new behavior patterns, increase existing skills, or reduce avoidance behavior in which the patient observes a person modeling adaptive behavior and is then encourage to imitate it. Shaping introduces new behaviors by reinforcing behaviors that approximate the desired behavior. Token Economy a form of positive reinforcement in which patients are rewarded for performing desired target behavior with tokens that they can use for desired purchases or activities. Role Playing acting out of a particular situation. Social Skills Training teaching smooth social functioning to those who do not manifest social skills, using the principles of guidance, demonstration, practice, feedback, resulting the acquisition of behaviors that will support community living. Aversion Therapy reduces unwanted but persistent maladaptive behaviors by applying an aversive or noxious stimulus when that maladaptive behavior occurs. EX: Snap a rubber band on the wrist when being bothered by intrusive thoughts Contingency Contracting a formal contract between the patient and the therapist defining what behaviors are to be changed and what consequences follow the performance of these behaviors.

ANTIANXIETY DRUGS: Benzodiazepines are CNS depressant Ex: a. Alprazolam (Xanax) b. Chlordiazepoxide (Librium) f. Flurazepam (Dalmane) j. Triazolam (Halcion) c. Clonazepam (Klonopin) g. Lorazepam (Ativan) d. Chlorazepate (Tranxene) h. Oxazepam (Serax) e. Diazepam (Valium) i. Temazepam (Restoril)

Pharmacologic Effect: Side Effects: Dry Mouth, Ataxia, Dizziness and Drowsiness, Nausea, Withdrawal symptoms (increased anxiety, flu-like symptoms and tremors)

ANXIETY DISORDERS

Anxiety disorders are diagnosed when anxiety no longer functions as a signal of danger or a motivation for needed change but becomes chronic and permeates major portions of the persons life, resulting in maladaptive behaviors and emotional disability. have many manifestations but anxiety is the key feature of each.Prevalence: More prevalent in women, people younger than 45 years, people who are divorced or separated and people of lower socioeconomic status.Types of Anxiety Disorders: Phobia Panic Disorder Obsessive-Compulsive Disorder (OCD) Generalized Anxiety Disorder (GAD) Acute Stress Disorder (ASD) Post- Traumatic Stress Disorder (PTSD)

RELATED DISORDERS:1. Anxiety Disorder due to a general medical condition.2. Substance-induced Anxiety Disorder directly caused by drug abuse, a medication, or exposure to a toxin.3. Separation Anxiety Disorder- excessive anxiety concerning separation from home or from persons/parents/caregivers to whom he is attached. ( occurs when it is no longer developmentally appropriate and before 18 years of age).4. Adjustment Disorder

GENERALIZED ANXIETY DISORDER

A person with GAD worries excessively and feels highly anxious at least 50% of the time for 6 months or more Has three or more of the following symptoms:1. uneasiness4. fatigue2. irritability5. difficulty thinking3. muscle tension6. sleep alterations

TREATMENT: Buspirone (BuSpar) SSRI antidepressants

POST TRAUMATIC STRESS DISORDER

Post traumatic Stress Disorder Disturbing pattern of behavior demonstrated by someone who has experienced a traumatic event. Example: natural disaster, combat or an assault, threat or death or serious injury and responded with intense fear, helplessness or terror.

3 Cluster of Symptoms:1. Reliving the event persistently re-experiences the event through memories, dreams, flashbacks or reactions to external cues about the event.2. Avoiding the reminders of event.3. Being on guard or hyper-arousal signs of increased arousal are the following: insomnia, hyperarousal or hypervigilance, irritability or angry outburst. Symptoms occur 3 months or more after the trauma. Can occur at any age including childhood Dissociation is a subconscious defense mechanism that helps a person protects his or her emotional self from recognizing the full effects of some traumatic event by allowing the mind to forget or remove itself from the painful situation or memory.

Types of Dissociative disorders:a. Dissociative Amnesia the client cannot remember important personal information usually of a traumatic stressful nature.b. Dissociative fugue the client has episodes of suddenly leaving the home or place at work without any explanation, traveling to another city, and being unable to remember his or her past or identity. He or she may assume a new identity.c. Dissociative Identity Disorder (formerly, multiple personality disorder). The client display two or more distinct identities or personality states that recurrently take control of his/her behavior. This is accompanied by inability to recall important personal information.d. Depersonalization disorder the client has persistent or recurrent feelings of being detached from his or her mental processes or body. This is accompanied by intact reality testing; the client is not psychotic or out of touch with reality.

APPLICATION OF THE NURSING PROCESS:

Assessment:A) Background:Reveals that the client has the history of trauma or abuse

B) General Appearance and Motor Behavior: Often appears hyper-alert and react to even small environmental noises with a startle response. Maybe very uncomfortable is the client too close physically and may require greater distance or personal space. May appear anxious or agitated and may have difficulty sitting still or may sit very still, seemingly to curl up with arms around knees.

C) Mood and Affect Nurse must remember that a wide range of emotions is possible, e.g. from passivity to anger. May appear frightened or scared, or agitated and hostile depending on his or her experience. When experiences a FLASHBACK, the patient appears terrified and may cry, scream or attempt to hide or runaway. When the client is DISSOCIATING, he or she may speak in different tone of voice or appear numb with a vacant stare. Report intense rage or anger or feeling dread inside and unable to identify any feelings or emotions.

D) Thought Process and Content Report reliving the trauma nightmares or flashbacks Intrusive, persistent thought about the trauma interfere on client focus on ADL. Report hallucinations or buzzing voices in their head Report fantasies in which they take revenge on their abuser.

E) Sensorium and Intellectual Processes Oriented to reality except if the client is experiencing flashback or dissociative episodes. With Memory Gaps period for which they have no clear MEMORIES. May be short or extensive and are usually related to the time of abuse or trauma.

F) Judgment and Insight Clients ability to make decisions or solve problems may be impaired.

G) Self- Concept Low Self-Esteem Believe they are bad people who somehow deserve or provoke the abuse. Think they are unworthy and damage Think they are going crazy and are out of control with no hope of regaining control. See themselves as helpless, hopeless, and worthless.

H) Roles and Relationships Great deal or difficulty with all types of relationships. Problems with authority figures- being unable to make directions from another or have another monitor her performance. Close relationship are difficult- because clients ability to TRUST is severely compromises. Avoidant behavior.

I) Physiologic Consideration Difficulty sleeping Overeating or lack of appetite Use alcohol or other drugs.

DATA ANALYSIS

Risk for Injury Anxiety Situational Low Self Esteem (during Panic Attack) Ineffective Coping Poswerlessness Ineffective Role Performance Disturbed Sleep pattern

OUTCOME IDENTIFICATION1. The client will be physically safe.2. The client will distinguish between ideas of self harm and taking action on those ideas.3. The client will demonstrate healthy, effective ways of dealing with stress.4. The client will express emotions nondestructively.5. The client will establish a social support system in the community.

INTERVENTION:1. Promoting the clients safety priority. Assess the client potential for self harm and suicide and take action accordingly. Nurse and treatment team must provide safety measures when the client cannot do so. Nurse can talk with the client about the difference between having self harm thoughts and taking action on those thoughts Help the client develop plan for going to safe place when having destructive thoughts or impulses so that he or she can calm down and wait until they pass.

2.Helping the client cope with stress and emotions. Use GROUNDING TECHNIQUE to help client who is dissociating or experiencing a flashbacks. Reorient the client by saying John, Im here with you, my name is Roland, Im the nurse working with you today. You are in the hospital?, today is Monday, July 2, 2007. Can you open your eyes and look at me? John, my name is Roland Validates clients feeling of fear but try to increase contact to reality:I know this is frightening to you, but you are safe nowWhat are you feeling?What are you touching?do you feel your feet on the floor? During dissociative experience or flashback, help client change body position but do not grab or force client to stand up. Use supportive touch when client responds well to it. Teach deep breathing and relaxation techniques Use distraction techniques such as physical exercises, listening to music, talking with others to engaging in a hobby or enjoyable activities. Help to make a list of activities and keep materials client on hand to engage client when feelings are intense.1. Help the client promote in self-esteem. Refer to client as survivor rather than a victim allows the client to think they are strong enough to survive their ordeal. Establish social support system in the community- local hotline crisis, friends and family.

Medication: Paroxetine (Paxil) Sertraline (Zoloft)

ACUTE STRESS DISORDER

Is similar to PTSD in that the person experienced a traumatic situation but the response is more dissociative. Onset is within 4 week after event and duration is 2 days to 4 weeksAssessment: History of exposure to traumatic event Avoidance of stimuli related to trauma ( feelings, thoughts, people, conversations, places, activities) and distress when exposed to reminders of the traumatic event. Increased arousal or anxiety: sleep disturbance, hypervigilance, startle response, irritability, decreased concentration. Flashbacks re- experiencing and relieving the event through dreams, nightmares, illusions. Impairment in functioning occupational, social, family. Dissociative symptoms:a. absence of emotions, numbing, detachment- may not be able to show emotions such as affection.b. Daze decreased awareness of surroundingsc. Amnesiad. depersonalization Cross sensitization overreaction to other stimuli that resemble the original traumatic event. Defense Mechanism: denial, suppression, and repression.

Nursing Intervention:1. Desensitization through gradual exposure to stressful stimuli.2. Medications:3. Nursing Interventions:a. Strengthen survivors sense of control over their lives.>Familiarizing the individuals with the symptoms of PTSD and their basis.>Teaching coping skills that channel anger and manage stress.>Assisting with activities of daily living (ADL) and basic self- care skills.>Allowing the survivors to make as many decisions as possible, based on their ability.

b, Create a sense of safety.c. Provide support. Help survivor to grieve over their losses so they can move forward in their lives.d. Assist in forming meaningful goals and connections with other people.

PANIC DISORDER

Composed of discrete episodes of panic attacks, that is 15-30 minutes of rapid, intense, escalating anxiety in which the person experiences great emotional fears as well physiologic discomfort. Displays four or more of the following symptoms: palpitations, sweating, tremors, shortness of breath, sense of suffocation, chest pain, nausea, abdominal distress, dizziness, paresthesias, chills or hot flashes. Panic disorder is diagnosed when a person has recurrent unexpected panic attack followed by a least 1 month of persistent concern or worry about future attacks Onset of panic disorder peaks in late adolescence and the mid-30s. A person with panic disorder experiences this emotional and physiologic responses without this stimulus.

TREATMENT: Treated with COGNITIVE-BEHAVIORAL techniques deep breathing and relaxation and medication such as:e. SSRIs antidepressants (Selective Serotonin Reactive Inhibitors)f. Tricyclic antidepressantg. Benzodiazepinesh. Antihypertensive drugs (cataprespropanolol)APPLICATION OF THE NURSING PROCESS:AssessmentHistory: Client usually seeks treatment for panic disorder after he or she has experienced several panic attacks. Client may report, I feel like Im going crazy, I thought I was having a heart attack, but the doctor says its anxiety. Usually the client cannot identify any trigger for these events.

General Appearance and Motor Behavior: May appear entirely normal Automatism automatic, unconscious mannerism, may be apparent..Examples: tapping fingers, twisting hair- geared towards anxiety relief.

Moods and Affect Anxious, worried, tense, depress, serious or sad. Express anger at his or herself Derealization (sensing that things are not real)

Thought Processes and Content During a panic attack, the client may become overwhelmed, believing that he or she is dying, losing control or going crazy. May even consider suicide Worry about the next panic attack

Sensorium and Intellectual Processes May become confused and disoriented during the panic attack.

Self Concept Client often make self-blaming statements such as I cant believe Im so weak and out of control or I used to be a happy well-adjusted person.

Roles and Relationships Typically avoids people, places and events associated with previous panic attack

Physiologic and self Care Concerns With problems on sleeping and eating Experience loss of appetite or eat constantly

OUTCOME IDENTIFICATION1. The client will be free from injury.2. The client will verbalize feelings3. The client will sleep at least 6 hours per night.4. The client will demonstrate use of effective coping mechanism.5. The client will demonstrate effective use of methods to manage anxiety response6. The client will verbalize a sense of personal control.7. The client will establish adequate nutritional intake.

INTERVENTION: Provide a safe environment and ensure clients privacy during the attack- if the environment is over stimulating, the client should move into a less stimulating place (a quiet place reduces anxiety and provides privacy for the client) Remain in the client during a panic attack- to calm her down and to assess client behaviors and concern. Talk to client in a calm reassurance voice Teach the client to use relaxation technique- deep breathing exercises, guided imagery Help the client to use cognitive restructuring techniques. Engage client to explore how to decrease stressors and anxiety-provoking situations.

OBSESSIVE-COMPULSIVE DISORDER

OBSESSION are recurrent, persistent intrusive and unwanted thoughts, images, or impulses that cause markedly anxiety and interfere with interpersonal, social or occupational function.

COMPULSION are realistic or repetitive behaviors or mental acts that a person carries out continuously in an attempt to neutralize anxiety.

Obsessive-compulsive disorder (OCD) is diagnosed only when these thoughts, images and impulses consume the person or he or she is compelled to act out the behavior to a point at which they interfere with personal, social and occupational function. OCD can start in childhood especially in males

TREATMENT:A. Behavior Therapy Exposure- involves assisting the client to deliberately confront the situations and stimuli that he or she usually avoids. Response Prevention focuses on delaying or avoiding performance of rituals.

MEDICATION: Clomipramine (Anafranil) a drug of choice, it decrease obsession and alleviate rituals.

APPLICATION OF THE NURSING PROCESS:Assessment:A. History: Client usually seeks treatment only when obsession becomes too overwhelming, compulsions interfere with daily living or both. Most treatment is outpatient. The client reports that rituals began many years before; some begin early as childhood.

B. General Appearance and Motor Behavior Client seems tense, anxious, worried, and fretful. Overall appearance is unremarkable; that is, nothing observable seems to be out of the ordinary

C. Mood and Affect Clients report ongoing, overwhelming feelings of anxiety is response to obsessional thoughts, images, or urges. Look sad and anxious.

D. Thought Processes and Content Client describes the obsessions as arising from nowhere during the middle of normal activities.

E. Sensorium and Intellectual Processes There is intact intellectual functioning The client may describe difficulty concentrating or paying attention when obsessions are strong. No impairment of memory or sensory functioning.

F. Judgment and Insight Recognizes that obsession is irrational but he or she cannot stop them Client can make sound judgment (I know the house is safe) but cannot act on them. When anxiety overwhelms, client will engage in ritualistic behavior

G. Self Concept Clients voices concern that he or she is going crazy. There is feeling of powerlessness to control the obsession or compulsion that contributes to low self-esteem.

H. Roles and Relationship Relationship suffers as family and friends tire of repetitive behavior, and the client is less available to them.

I. Physiologic and Self-Care Considerations Have trouble sleeping Loss of appetite or unwanted weight loss Personal hygiene may suffer

OUTCOME IDENTIFICATION:1. The client will complete daily routine activities within a realistic time frame.2. The client will demonstrate effective use of relaxation techniques.3. The client will discuss feelings with another person.4. The client will demonstrate effective use of behavior therapy techniques.5. The client will spend less time performing rituals.

INTERVENTION:1. Offer encouragement, support, and compassion.2. Be clear with the client that you believe he or she change.3. Encourage the client to talk about feelings, obsessions and rituals.4. Gradually decrease time for the client to carry out ritualistic behavior.5. Assist the client to use exposure and response prevention behavioral techniques.6. Encourage client to use techniques to manage and to tolerate anxiety responses.7. Assist client to complete daily routine and activities.

PHOBIAS

Is an illogical, intense, persistent fear of a specific object or social situation that cause extreme distress and interferes with normal functioning. Usually do not result from past, negative experiences

3 Categories of phobia1. Agoraphobia Acute anxiety on crowd and fear of being alone.2. Specific phobia irrational fear of an object or situation3. Social phobia anxiety provoked by certain social or performance situations.

Diagnosis of phobic disorder is made only when the phobic behavior significantly interferes with the persons life by creating marked distress or difficulty in interpersonal or occupational functioning.

Categories of Specific phobia:1. Natural environmental phobias fear of storm, water, height, or other natural phenomena.2. Blood-injection phobia fear of seeing ones own or others blood, traumatic injury, or an invasive medical procedure such as an injection.3. Situational phobia- fear of being in a specific situation such as a bridge, tunnel, elevator, small room, hospital or airplane.4. Animal phobia fear of animal or insects (usually a specific type). Often this fear develops in childhood and can continue through adulthood in both men and women. Cats and dogs are the most common phobic objects.5. Other types of specific phobias: for example, fear of getting lost while driving if not able to make all right turns (and no left turns) to get to ones destination. usually occur in childhood or adolescent.

Social Phobia is also known as social anxiety disorder. Person becomes severely anxious to the point of panic or incapacitation when confronting situations involving people.Example: Making speech, attending a social engagement alone, interacting with the opposite sex or with strangers, and making complaints. Fear is rooted in low self esteem and concern about others judgment. Fears on looking socially inept, appearing anxious, or doing something embarrassing such as burping or spilling food. Other social phobias: fear of eating in public, using public bathrooms, writing in public, or becoming the center of attention. Peak age of onset is middle adolescence.TREATMENT:1. Behavioral Therapy Systematic Desensitization- in which the therapist progressively exposes the client to the threatening object in a safe setting until the clients anxiety decreases.Example: fear of flying, airplane, walk in the airport, taking a short ride in a plane.

Flooding form of rapid desensitization in which a behavioral therapist confronts the client with phobic object (either a picture or the actual object) until it no longer produces anxiety.= Because the clients worst fear has been realized and the client did not die, there is a little reason to fear the situation anymore.= This method is highly anxiety producing and should be conducted only by a trained psychotherapist under controlled circumstances and with the client consent.

2. MEDICATION: No pharmacological intervention

PSYCHOPHYSIOLOGIC RESPONSES

Psychosomatic Disorders (Psychophysiologic Disorders)= refer to disorders characterized by somatic complaints for which the organic cause could be demonstrated and are the result of emotional conflict.

General Characteristics1. Involves organ system innervated by the ANS.2. Physiologic changes involved are those that usually accompany emotional response but more intense autonomic nervous system sustained.3. Symptoms are thus physiologic rather than symbolic, the effect being expressed through the viscera.4. May produce structural organic changes if psychosomatic symptoms persist.5. Somatic symptoms afford generous secondary gains.

The nurse and other health team must never assume that patient with PPD are not sick.

Theories of psychopathology1. Repressed conflict/events and leads to increase in the patients level of anxiety.2. A certain personality type (type A) is particularly prone to the development of certain physical illness.3. This theory places emphasis on the symbolism of illness.4. Organ weakness theory: All humans have one body system that is relatively less healthy than the other.5. Patient with psychophysiologic disorder often have needs for dependency, attention, love and security.

* When these needs cannot be met the person clings unconsciously to this disability as means of achieving satisfaction.

6. Psychophysiologic Disorders:

ORGAN/SYSTEM DISORDER G.I.T - Peptic Ulcer Cardiovascular - Essential hypertension Respiratory - Bronchial asthma Integumentary - ALLERGIC Dermatitis Musculoskeletal - Arthritis Masochistic Behavior

Concept in Giving Nursing Care1. Persons who develop psychophysiologic disturbances have unconscious emotional conflict that increases their anxiety and interferes with their effectively meeting their needs.2. The physical illness is the result of an expression of this unconscious conflict and serves as a means of lowering anxiety level.3. The physical illness is real in that those are demonstrable organic changes that may be life-threatening.

Nursing Care:1. The nurse must fully understand and accept the fact that these people are physically ill and that these symptoms may reach in life-threatening proportion.2. During the acute episode of illness meeting the physical needs of the client is for primary importance.3. It must be understood that many of the clients feelings unacceptable to him and therefore acceptance of him and his feelings by the nurse is of primary importance.4. The nurse carries out attitude that she believes the individual will get better if he merely exerted more control over his emotion.

SOMATOFORM DISORDERS

= Expression of needs through body language: Symbolic repressed feeling is related with over-excited organ. It is characterized as the presence of physical symptoms that suggest a medical condition without a demonstrable organic basis. These are chronic and recurrent, so progress toward treatment outcomes can be slow and difficult.

Coping Technique:To gain attention * Punishing of self and othersRationalization

3 Central features of Somatoform disorders:1. Physical complaints suggest major medical illness but have no demonstrable organic basis.2. Psychologic factors and conflicts seem important initiating, exacerbating, and maintaining the symptoms.3. Symptoms or magnified health concerns are not under the clients conscious control.

ETIOLOGY: Psychosocial theorists believe that people with somatoform disorders keep stress, anxiety, or frustration inside rather than expressing them outward. This is called internalization. When clients express these internalized feelings and stress through physical symptoms is called Somatization Internalization and Somatization are both unconscious defense mechanism Physical symptoms worsen when they experienced another conflicts or emotional stress The worsening of physical symptoms helps them to meet psychological needs for security, attention, and affection through primary and secondary gains.

PRIMARY GAINS is the direct benefit clients experience such as relief from anxiety, conflicts, or distress.e.g. If the client is physically sick, she doesnt have to deal with problems with the children

SECONDARY GAINS is the personal benefit derived from illness, such as special attention or comfort received from others. e.g.receiving back rub, being brought tea or breakfast in bed.

Types of Somatoform:1. Body Dysmorphic Disorder-Preoccupation with an imagined or exaggerateddefect in physical appearance in a normal appearing person. E.g. Nose is too large or the teeth- common in both gender2. Conversion Disorder (Conversion reaction) An unconscious process through which the anxiety is converted into physical and physiologic symptoms. Usually unexplained sudden deficit of sensory or motor function (blindness, paralysis) Key feature: la belle indifference - a seeming lack of concern or distress. tends to develop during adolescence or early adulthood but may occur at any age. More common among women and occurs between 10 and 35 years of age Patients with this disorder may have feelings of guilt, unexpressed anger, frustrations and low self esteem.

Nursing Intervention:a. Focus on anxiety reduction symptoms will be relieved when anxiety is relieved. diversional activities and administration of anti-anxiety medications.b. Matter of fact attitude.c. Relaxation trainingd. Psychotherapye. Hypnotherapy

c. Hypochodriasis- Morbid preoccupation with body functions or fear of serious disease. Motive is unrecognizable or unconscious. They may interpret normal body sensations as signs of disease. Also known as Disease phobia- fear that one has a serious disease (disease conviction).- fear that one will get a serious disease (disease phobia)- common in both gender- occur at any age

Six Major Criteria:1. Preoccupation with having a serious disease based on misinterpretation of physical symptom.2. This conviction that he is ill is maintained despite medical reassurance that nothing is wrong.3. Preoccupation that is not as intense or distorted as delusional disorder or as restricted as body dysmorphic disorder.4. Preoccupation that causes significant distress and impaired social and occupational functioning.5. Disorder duration of at least 6 months; and6. The symptoms are not caused by anxiety, somatoform, and major depressive disorders.

Nursing Intervention:1. Establish trust and show empathy.2. Reassure client and family that there is no medical illness by showing laboratory results, x-ray findings, and other tangible evidence but acknowledge the symptoms as real for the person and discuss with the patient that they are caused by a disease fear.3. Exposure techniques.4. Explore alternative coping skills-identity stressors.5. Set limits on the time spent with the client because of the tendency of the client to manipulate.6. Do not provide secondary gain, do not focus on the symptoms during interaction with the patient but encourage verbalization of feelings.7. Diversional activity.8. Medications SSRI (fluoxetine {prosac}, paroxetine {paxil}, and fluvoxamine maleate {luvox}).

d. Somatization disorder (Briquets Syndrome)Somatization - is defined as the transference of mental experiences and states into bodily symptoms.Somatization Disorder Somatic complaints of several years duration for which medical attention has been sought but that are apparently not due to any physical disorder. Occurs before age 30 and runs a chronic course. Common in women Characterized by multiple physical symptoms which includes a combination of pain, gastrointestinal, sexual and pseudoneurologic symptoms.

DIAGNOSTIC Criteria: onset of physical complaints before age 30 a history of pain affecting at least four different body parts two or more GI symptoms at least one sexual or reproductive system at least one neurologic symptom (excluding pain) the diagnosis is supported by the dramatic nature of the complaints and the patients exhibitionistic, dependent, manipulative, and sometimes suicidal behavior.***Undifferentiated somatoform disorder

Symptoms: Nausea and vomiting, intolerance to several different food, erectile/ejaculation problems, irregular menses, excessive menstrual bleeding, blindness, seizures, deafness, paralysis, difficulty swallowing/breathing, dissociative symptoms such as amnesia, Dizziness, Shortness of breath, Dysmenorrhea and chest pain, headache, sexual intercourse (dyspareunia), painful urination (dysuria).

Key Feature: La belle indifference

Nursing Intervention:a. Usually, the treatment is calm, firm, supportive relationship.b. Avoid judgmental approach and such comments as There is nothing wrong with you, or Everything is alright.c. Matter of fact manner about the diagnosis but acknowledge the symptoms as real and distressing to the patient. Provide symptomatic care.d. Provide empathy. Reassure that although he has an impairing condition, it is not life threatening and inform the patient of the different therapies availablee. Set limits.

e. Pain disorder (Psychalgia) Primary physical symptom of pain, which generally is unrelieved by analgesics and greatly affected by psychological factors in terms of onset, severity, exacerbation, and maintenance. Commonly seen in medical practice, which occur in 4% to 9% Common in women Occur at any age

General Characteristic:1. Physical symptoms without organic basis.Examples: blindness, seizures, paralysis, anosmia, aphonia, Coordination disturbance, Anesthesia or paresthesia2. La Belle indifference Lack of concern regarding the severity of the above symptoms.3. Doctor hopping4. Excessive use of analgesic with minimal relief from pain5. Assumption of an invalid role.6. Impairment in social and occupational functioning due to pre-occupation with physical complaints.

Nursing Intervention: Same as Conversion Disorder

Somatization = is defined as the transference of mental experiences and states into bodily symptoms.Somatization Disorder Somatic complaints of several years duration for which medical attention has been sought but that are apparently not due to any physical disorder. Occurs before age 30 and runs a chronic course. Symptoms: Nausea and vomiting, intolerance to several different food, erectile/ejaculation problems, irregular menses, excessive menstrual bleeding, blindness, seizures, deafness, paralysis, difficulty swallowing/breathing, dissociative symptoms such as amnesia, Dizziness, Shortness of breath, Dysmenorrhea and chest pain, headache, sexual intercourse (dyspareunia), painful urination (dysuria)

RELATED DISORDERS:a. Malingering is the intentional production of false or grossly exaggerated physical or psychological symptoms.- motivated by external incentives such as avoiding work, evading criminal prosecution, obtaining financial compensation, or obtaining drugs.b. Factitious Disorder(Munchausen syndrome) occurs when a person intentionally produces or feigns physical or psychological symptoms solely to gain attention. People with factitious disorder may even inflict injury on themselves to receive attention.- A variation of factitious disorder is Munchausen syndrome by proxy, occurs when a person inflicts illness or injury on someone else to gain the attention of emergency medical personnel or to be a hero for saving the victim.Coping Strategies:a. Emotion-focused coping strategies Help clients relax and reduce feelings of stress Includes progressive relaxation, deep breathing, guided imagery, and distractions such as music or other therapies (does not eliminate their pain or physical symptoms; rather, the focus is helping them to manage or diminish the intensity of the symptoms.)b. Problem-focused coping strategies Help to resolve or solve the clients behavior or situation or manage life stressors. Includes learning problem-solving methods, applying the process to identified problems, and role playing interactions with others

SLEEP DISORDERS Is a medical disorder of the sleep patterns of a person or animal. Some sleep disorders are serious enough to interfere with normal physical, mental and emotional functioning. Polysomnography is a test commonly ordered for some sleep disorders.

PHYSIOLOGY OF SLEEP: NREM stage 1: This is a stage between sleep and wakefulness. The muscles are active, and the eyes roll slowly, opening and closing moderately. NREM stage 2: theta activity In this stage, it gradually becomes harder to awaken the sleep NREM stage 3: Formerly divided into stages 3 and 4, this stage is called slow-wave sleep. The sleeper is less responsive to the environment; many environmental stimuli no longer produce any reactions. REM: The sleeper now enters rapid eye movement (REM) where most muscles are paralyzed. REM sleep is turned on by acetylcholine secretion and is inhibited by neurons that secrete serotonin. This level is also referred to as paradoxical sleep because the sleeper is harder to arouse than at any other sleep stage. Vital signs indicate arousal and oxygen consumption by the brain is higher than when the sleeper is awake. An adult reaches REM approximately every 90 minutes, with the latter half of sleep being more dominated by this stage. The function of REM sleep is uncertain but a lack of it will impair the ability to learn complex tasks.

TYPES OF SLEEP DISORDERS

1.Primary insomnia: Chronic difficulty in falling asleep and/or maintaining sleep when no other cause is found for these symptoms.2.Bruxism: Involuntarily grinding or clenching of the teeth while sleeping.3. Delayed sleep phase syndrome (DSPS): inability to awaken and fall asleep at socially acceptable times but no problem with sleep maintenance, a disorder of circadian rhythms. (Other such disorders are advanced sleep phase syndrome (ASPS), non-24-hour sleep-wake syndrome (Non-24), and irregular sleep wake rhythm, all much less common than DSPS, as well as the transient jet lag and shift work sleep disorder.)4. Hypopnea syndrome: Abnormally shallow breathing or slow respiratory rate while sleeping.5. Narcolepsy: Excessive daytime sleepiness (EDS) often culminating in falling asleep spontaneously but unwillingly at inappropriate times.6. Cataplexy: a sudden weakness in the motor muscles that can result in collapse to the floor.7. Night terror: Pavornocturnus, sleep terror disorder: abrupt awakening from sleep with behavior consistent with terror.8. Parasomnias: Disruptive sleep-related events involving inappropriate actions during sleep; sleep walking and night-terrors are examples.9. Periodic limb movement disorder (PLMD): Sudden involuntary movement of arms and/or legs during sleep, for example kicking the legs. Also known as nocturnal myoclonus. See also Hypnic jerk, which is not a disorder.10. Rapid eye movement behavior disorder (RBD): Acting out violent or dramatic dreams while in REM sleep, sometimes injuring bed partner or self (REM sleep disorder or RSD)11. Restless legs syndrome (RLS): An irresistible urge to move legs. RLS sufferers often also have PLMD.12. Situational circadian rhythm sleep disorders: shift work sleep disorder (SWSD) and jet lag.13. Sleep apnea, obstructive sleep apnea: Obstruction of the airway during sleep, causing lack of sufficient deep sleep, often accompanied by snoring. Other forms of sleep apnea are less common. When air is blocked from entering into the lungs, the individual unconsciously gasps for air and sleep is disturbed. Stops of breathing of at least ten seconds, 30 times within seven hours of sleep, classifies as apnea.14. Sleep paralysis: is characterized by temporary paralysis of the body shortly before or after sleep. Sleep paralysis may be accompanied by visual, auditory or tactile hallucinations. Not a disorder unless severe. Often seen as part of narcolepsy.15. Sleepwalking or somnambulism: Engaging in activities that are normally associated with wakefulness (such as eating or dressing), which may include walking, without the conscious knowledge of the subject.16. Nocturia: A frequent need to get up and go to the bathroom to urinate at night. It differs from Enuresis, or bed-wetting, in which the person does not arouse from sleep, but the bladder nevertheless empties.[3]17. Somniphobia: A cause of sleep deprivation. Somniphobia is a dread/ fear of falling asleep or going to bed. Signs of illness include anxiety and panic attacks during attempts to sleep and before it. 18. Kleine-Levin syndrome or Sleeping Beauty syndrome is a neurological disorder characterized by recurring periods of excessive amounts of sleeping and eating. At the onset of an episode the patient becomes drowsy and sleeps for most of the day and night (hypersomnolence), waking only to eat or go to the bathroom. When awake, the patients whole demeanor is changed, often appearing spacey or childlikeTreatments for sleep disorders generally can be grouped into four categories: Behavioral and psychotherapeutic treatment Rehabilitation and management Medication Other somatic treatment

PERSONALITY DISORDERSPersonality Includes perceptions, attitudes and emotions Personality can be defined as an ingrained enduring pattern of behaving and relating to self, others, and the environment.Personality Disorders Diagnosed when personality traits become inflexible and maladaptive and significantly interfere with how a person functions in society or cause the person emotional distress. Long standing because personality characteristics do not change easily

Diagnosis of PD is based on two or more deviations on the following1. Ways of perceiving and interpreting self, other people, and events. (cognition)2. Range, intensity, lability, and appropriateness of emotional response (affect)3. Ability to control impulses or express behavior at the appropriate time and place (impulse control)Categories of Personality Disorders Based on DSM IV-TR Cluster A includes people whose behavior appear odd or eccentric and includes paranoid, schizoid, and schizotypal personality disorders. Cluster B includes people who appear dramatic, emotional or erratic and includes antisocial, borderline, histrionic, and narcissistic personality disorders. Cluster C includes people who appear anxious or fearful and includes avoidant, dependent, and obsessive-compulsive personality disorders.Onset and Clinical Course: Common, occurring in 10% to 13% of the general population Higher in lower socioeconomic groups Treatment resistant

ETIOLOGYBiologic Theories Compose of temperament and character

Temperament refers to biologic processes of sensation, association, and motivation that underlie the integration of skills and habits based on emotion. Temperament is about our habit systems (which roughly equates to the ancient Greek concept of the "four humors") namely:Traits :1. Harm avoidance - The fear system that mediates responding to punishment and pain.2. Novelty seeking - Looking for pleasure, which leads to rage when frustrated.3. Reward dependence - Allows us to be sensitive to social cues that in turn allows social intimacy.4. Persistence - Allows us to deal with expectations about whether we will get rewarded or not. We see it in very conscientious people.FOUR TEMPERAMENT TRAITS

PSYCHODYNAMIC THEORIES

Character consists of concepts about the self and the external world.

THREE MAJOR CHARACTER TRAITS:

Signs and symptoms of cluster A (odd, eccentric) personality disorders

Paranoid personality disorder Suspiciousness and mistrust of people characterize the person with a paranoid disorder Interpret the action of others as personal threats, which results in increase anxiety and the need for defensiveness Belief that others are lying, cheating, exploiting or trying to harm you Perception of hidden, malicious meaning in benign comments Inability to work collaboratively with others Emotional detachment Hostility toward others Sometimes with ideas of reference, have a blunted affect Capable of close relationships with a select few, however, they might be suspicious or jealous of those close to them Unique Causes: some evidence has suggested that it tends to occur in biologic relatives of identified patients with schizophrenia. More common in men than women 0.5%-2.5% of the general population Defense Mechanism Used: ProjectionNursing Interventions: Approach in a formal, business-like manner and refrain from social chitchat or jokes Involve in formulating their plans of care Teach client to validate ideas before taking action.

Schizoid personality disorder

People schizoid personalities do not want to be involved in interpersonal or social relationships and keep people at an emotional distance. Fantasizing rich and extensive Extreme introversion self absorbed and loner Emotional distance, even from family members lack of desire for involvement with others in all aspects of life. Solitary activities are more gratifying compared to real persons and social situations Fixation on your own thoughts and feelings indecisive and lack future goals and direction Emotional detachment marked difficulty experiencing and expressing emotions particularly anger and aggression Occurs 0.5% - 7% of the general populationNursing Interventions: Improve clients functioning in the community- Nurse can make referrals to social services or appropriate local agencies for assistance. Assist client to find case manager that can help the client to obtain services and health care, manage finances, and so on.

Schizotypal Personality Disorder

Appear similar to patients with mild schizophrenia and do not meet enough of the criteria to be diagnosed with psychosis or schizophrenia These patients have problems in thinking, perceiving, and communicating Indifference to and withdrawal from others "Magical thinking (experience transient psychotic episodes in response to stress) the idea that you can influence people and events with your thoughts Odd appearance, elaborate style of dressing (unkempt, clothes often ill-fitting, do not match and stained and dirty), speaking (coherent but may be loose and bizarre) and in interacting with others Belief that messages are hidden for you in public speeches and displays Suspicious or paranoid ideas anxious to strangers Paranoid ideation, ideas of reference, and odd beliefs are some of the most prevalent and unchangeable criteria for this disorder 3%-5% of the population; slightly common in men than women Unique Causes: A family with Schizophrenia are at risk for developing this disorderNursing Interventions Development of self-care skills Improve community functioning- Ask client to make a list of people in the community with whom they must have contact (telephone or written) Social skills training to help clients to talk clearly with others and to reduce bizarre conversations.

Signs and symptoms of cluster B (dramatic, emotional) personality disorder

Histrionic personality disorder

2-3% of the gen.popul. Excessive sensitivity to others' approval Attention-grabbing, often sexually provocative clothing and behavior - Speech is usually colorful and theatrical, full of superlative adjectives Excessive concern with your physical appearance False sense of intimacy with others refer almost all acquaintances as dear Constant, sudden emotional shifts Have variety of vague physical complaints or relate exaggerated versions of physical illnessNursing Interventions: Teach social skills Provide factual feedback about behavior should focus on appropriate alternatives, not merely criticism

Narcissistic personality disorder 1-2% in general population; mostly in men Inflated sense of and preoccupation with your importance, achievements and talents (sense of entitlement) Constant attention-grabbing and admiration-seeking behavior Inability to empathize with others Excessive anger or shame in response to criticism Manipulation of others to further your own desires Nursing Interventions: Matter-of-fact approach Teach client any needed self-care skills.

Antisocial (formerly, sociopathic, psychopathic or dyssocial personality disorder) personality disorder The main feature is a pattern of disregard for the rights of others, which is usually demonstrated ny repeated violations of the law Only 3% of the general population; common in men Onset: is in childhood and adolescence Hx: childhood= enuresis, sleep walking and syntonic act of cruelty- adolescence engaged in lying, vandalism, sexual promiscuity Chronic irresponsibility and unreliability and substance abuse Lack of regard for the law and for others' rights Persistent lying and stealing Aggressive, often violent behavior Lack of remorse for hurting others Lack of concern for the safety Unique Causes: a. Influence of genetics and the environmentb. Biologic findings has a weak response to stress in the autonomic nervous system, as evidenced by low heart rate and lack of increase level of anxiety.c. Brain scan indicate dysfunction in the prefrontal cortex, frontal temporal and amygdala-hippocampal regions of the brainNursing Intervention:1. Stating the behavioral limit (describing the unacceptable behavior)2. Identifying the consequences if the limit exceeded3. Identifying the expected or desired behavior. Confrontation (matter-of-fact) Point out problem behavior Keep client focused on self Teach the client to solve problems effectively and manage emotions of anger and or frustrationProblem Solving Skills:1. Identifying the problem2. Exploring alternative solutions and related consequences3. Choosing and implementing alternatives4. Evalu