Anxiety Disorders and Dissociative Disorders

West Coast UniversityNURS 204

Psychiatric / Mental Health Nursing

Learning Objectives

Identify theories in understanding anxiety disorders and dissociative disorders

Explain the concept of anxiety and how it relates to anxiety disorders and dissociative disorders

Compare and contrast both the common themes and distinctive characteristics of anxiety disorders with dissociative disorders.

Incorporate how dissociation serves as a defense mechanism for some individuals experiencing trauma into the care of clients with dissociative disorders

Conduct a comprehensive assessment in the care of clients with anxiety and dissociative disorders.

Learning Objectives

Design a plan of care for intervening into mild, moderate, severe, and panic levels of anxiety.

Educate clients and their families about pharmacologic and non-pharmacologic measures for anxiety disorders and dissociative disorders

Identify the possible personal challenges in caring for clients with anxiety disorders and dissociative disorders.

Theories: Anxiety Disorders

Biological changes in the brainNoradrenergic system is sensitive to norepinephrine; locus ceruleus is involved in precipitating panic attacks.

Dopamine system involved in pathophysiology of OCD.

GABA dysfunction affects development of panic disorder.

Locus Caeruleus

Theories: Anxiety Disorders - continued

Abnormal control of glutamate plays role in anxiety disorders.

Hormonal changes in pregnant women affect certain anxiety disorders.

Lactic acid may precipitate anxiety.Caffeine and nicotine may trigger panic attacks.Genetic theories: strong evidence for familial or genetic predisposition for anxiety disorders

Psychosocial theories: in psychoanalytic theory, anxiety is viewed as sign of psychologic conflict; anxiety is the outcome of repressing forbidden impulses

Theories: Anxiety Disorders - continued

Behavioral theory Anxiety is a learned response that can be unlearned.

Compulsive behavior is a maladaptive attempt to alleviate anxiety.

Behavior modification teaches new ways to behave

Humanistic theories: Environmental stressors, biological factors, and intrapsychic fears cannot be dealt with separately but rather as they interact with one another.

Treatment approaches are integrative.

Anxiety

A universal experienceA normal response that usually helps cope with threatening situations

Anxiety disorders are characterized by anxiety so disabling as to adversely affect day-to-day functioning

Affects all age groups

Anxiety - continued

Anxiety disorders are most common of mental illnesses

All anxiety disorders have in common excessive, irrational fear and dread

Anxiety is either a dominant disturbance or an avoidance behavior

Free-floating anxiety is unrelated to a specific stimulus

Anxiety - continued

Panic disorderPhobia

Social Phobia Agoraphobia Specific Phobia

Generalized Anxiety Disorder (GAD)Obsessive Compulsive DisorderPost-Traumatic Stress DisorderAcute Stress Disorder

Panic Disorder

Recurrent attacks of severe anxiety lasting a few moments to an hour.

No stimulus but occur suddenly and spontaneously.Experience physical symptomsMimic symptoms of MI and mitral valve prolapse

Phobias

Agoraphobia: Fear of being alone or in public places from which escape might be difficult or help might not be available.

Social Phobia: Fear of extreme embarrassment.Specific Phobia: Fear of specific objects and

situations

Generalized Anxiety Disorder (GAD)

Pervasive, persistent anxiety of at least 6 months’ duration but without phobias, panic attacks, or obsessions and compulsions.

Chronic feeling nervousness and apprehension for no apparent reason and is unable to control the worry.

Unable to relax or stop worrying.Irritable, muscle tension, insomnia, SOB, and

dizziness.

Obsessive-Compulsive Disorder

Obsession: recurring thought that cannot be dismissed from consciousness.

Compulsion: uncontrollable, persistent urge to perform certain acts or behavior in order to relieve unwanted thoughts.

Fear that they will harm someone.Trivial, ridiculous, morbid, violent or contamination.

Common Obsessive-Compulsive Behaviors

Repetitious hand washing – Urge to wash, scrub, or clean – Fear of disease or contamination.

Returning home often to make sure appliances are turned off – Need to recheck related to self-doubt – Fear of disaster.

Hoarding junk mail, receipts, and all types of papers – Need to keep everything – Fear of losing things.

Ritualistic counting of number of stairs climbed – Urge to count repeatedly – belief that counting will yield control and thus prevent making mistakes.

Post-Traumatic Stress Disorder

Experience of a significant stressor or traumaHyperarousal when reexperiencing the traumatic

event: unable to relax, hypervigilance, always “on edge”

Categories: Acute: symptoms last less that 3 months. Chronic: symptoms last 3 months or more. Delayed onset: at least 6 months have elapsed between

trauma and the occurrence of symptoms.

YOUR ASSESSMENT APPROACH: The Client with Anxiety Disorder

YOUR ASSESSMENT APPROACH: The Client with Panic Attack

Nursing Diagnosis:

FearAnxietyIneffective copingIneffective role performanceImpaired verbal communicationRisk for traumaDisturbed thought processIneffective tissue perfusionInsomnia

Nursing Outcome Identification: NOC

Client will demonstrate absence of physical manifestation of anxiety.

Client will identify indicators of own anxiety anxiety.Client will verbalize feelings of anxiety appropriately.Client will demonstrate the use new coping skills.

Plan of Care for Anxiety

Mild to moderate anxiety Use a calm, quiet approach Observe client’s verbal/nonverbal behavior Encourage client to verbalize feelings Teach relaxation techniques (meditation, guided imagery, etc.) when anxiety is mild

Simple physical activities often help reduce anxiety

Develop goal-oriented contract

Plan of Care for Anxiety - continued

Severe to panic levels of anxiety:First priority is to reduce anxiety to tolerable levels.

Stay with the client.Provide a safe and supportive milieu. Use a firm voice and short, simple sentences. Place client in quieter, smaller, less stimulating environment; focus the client’s diffuse energy on repetitive task or tiring task.

Administer antianxiety medication if ordered.

Dissociative Disorder

Theories: Dissociative Disorders

Biological factors Serotonin Limbic system Physical illnesses and certain drugs Various personality states in dissociative identity disorder have different activity in frontal and temporal lobes.

Genetic theories: Dissociative disorder occurs more often in first-degree biologic relatives

Theories: Dissociative Disorders - continued

Psychosocial theories: Current explanations are based on Freud’s dynamic concepts.

Repression of ideas leads to amnesia, to protect oneself from emotional pain.

Dissociative identity disorder is a result of childhood chronic trauma.

Behavioral theories: Dissociative disorders are learned behaviors that provide protection from a painful experience.

Humanistic theories: The person is a composite of life experiences, psychobiological factors, and interpersonal interactions.

Distinctive Characteristics of Dissociative Disorder

Consciousness, memory, identity, and perception of environment are impaired.

Dissociation is a defense against trauma that separates emotions from behaviors.

Dissociation is a response to extreme childhood trauma.

Dissociation Emotional numbing Impaired social relationships Separates emotions from behaviors

Dissociative Disorder

Dissociative amnesia Dissociative fugue Dissociative identity disorderDepersonalization disorder

Care of Clients with Dissociative Disorders

Most clients with dissociative disorder seen in community rather than inpatient settings

Obtain subjective and objective dataComplete psychosocial and physical assessmentDecide whether priority is to alleviate symptoms or reintegrate anxiety-producing conflict.

Behavioral modification helps alleviate some problematic behaviors.

Provide safe, supportive environment.Teach desensitization to conflict.Medication plays a key role in treatment.

YOUR ASSESSMENT APPROACH: The Client with Dissociative Identity Disorder

YOUR ASSESSMENT APPROACH: The Client with Depersonalization Disorder

Common Themes

Anxiety disorders and dissociative identity disorder originate in childhood.

Major common theme = disabling anxietyOther common features: personality and mood changes, distorted perceptions, inability to concentrate, memory impairment, defense mechanisms

Both anxiety and dissociative disorders may have underlying comorbid illnesses like depression or substance abuse.

Both disorders profoundly affect quality of life.Psychotropic medications and teaching adaptive coping are mainstays of treatment.

A holistic approach is best for caring for these clients.

Comprehensive Assessment

Conduct a history and physical exam. Gather subjective and objective information.Interview family member(s) if possible.Complete psychosocial assessment to discover source of anxiety.

Differentiate between anxiety and depression.Evaluate sleep and sleep quality.Complete suicide and homicide assessment.Major focuses for a client with dissociative disorder are identity, memory, and consciousness.

Client/Family Education

Medications used to treat anxiety disorders include benzodiazepines, tricyclics, SSRIs and SNRIs, lithium, beta blockers, alpha-adrenergic antagonists, atypical antipsychotics, and neuroleptics.

Teach about medication indications, side effects, and drug–drug interactions.

Client/Family Education - continued

Teaching about medicationsDrowsiness is a common side effect.Do not drink alcohol while taking.Drink decaffeinated beverages.Do not take other medications or adjust dosage in any way without consulting health care provider.

Client/Family Education - continued

Nonpharmacologic measures comprise effective coping skills:

CBT techniques (desensitization, reciprocal inhibition, cognitive restructuring)

Relaxation trainingIndividual or group therapyExercise and nutrition

Personal Challenges

Anxiety is contagious.The nurse may be impatient and irritated by somatic complaints.

It is important to identify the source of one’s own anxiety and consistently role-model adaptive behavior.

A client’s avoidance mechanism can be challenging to staff.

Some nurses feel overwhelmed and helpless in the face of clients’ pain and catharsis.

Ready answers are more likely to interfere with client’s communication.

Psychopharmacology - Anxiolytics

Anti-anxiety medication relieve insomnia, anti-convulsant, muscle relaxant, alcohol withdrawal

Side effect: Sedation, mental confusion, amnesia, ataxia

May cause withdrawal symptoms: anxiety, insomnia, seizure, muscle tension Important to taper dose by no more that 25% per week to prevent withdrawal symptoms

Psychopharmacology - Anxiolytics

Benzodiazepines Alprazolan - Xanax (0.25 - 4 mg/d) Chlordiazepoxide - Librium (50 - 300 mg/d) Clonazepam - Klonopin (0.25 - 4 mg/d) Clorazepate - Tranxene (15 - 10 mg/d Diazepam - Valium (15 - 40 mg/d) Lorazepam - Ativan (1 - 10 mg/d) Oxazepam - Serax (30 - 120 mg/d)

Psychopharmacology - Anxiolytics

Other Anxiolytics and Sleep Medication Buspiron - Buspar (10 - 60 mg/d) Zolpidem - Ambien (5 - 10 mg/d) Zaleplon - Sonata (10 mg/d) Eszopiclone -Lunesta (1-3 mg/d) Rameltoeon - Rozerem (8mg/d) Cholral Hydrate - Noctec (500 - 2000 mg/d) Diphenhydramine - Benadryl, Sominex, Nytol (25 - 100 mg/d)

Review Questions

The nurse is assessing a client who exhibits great discomfort and anxiety and continually asks to go home, as he is certain he will lose bladder control if he does not leave soon. This behavior is consistent with a diagnosis of:

1. Acute stress disorder.

2. Obsessive-compulsive disorder.

3. Agoraphobia.

4. Acrophobia.

Review Question

Which assessment question would indicate that the nurse understands the distinct characteristics of cognition in anxiety?

1. “Do you feel sad and/or hopeless?

2. “How often do you lose your temper?”

3. “How often do your criticize yourself?”

4. “How often do you worry about the past or future?”

Review Question

The development of an alternate personality, or alter, in the client with dissociative identity disorder usually arises as a response to:

1. Physical illness.

2. Substance abuse.

3. The demands of adulthood.

4. Chronic child abuse.

Review Question

The client experiences feelings of extreme fear that occur for no apparent reason and are accompanied by intense physical symptoms. The priority nursing intervention would be to:

1. Encourage the client to verbalize feelings.

2. Counsel the family on therapeutic responses.

3. Stay with the client.

4. Teach relaxation techniques.

Review Question

To evaluate the effectiveness of medications used to treat a client’s anxiety, the nurse should:

1. Monitor the client’s anxiety level.

2. Help the client understand the source of the anxiety.

3. Demonstrate patience and project a sense of calm.

4. Expect SSRIs to cause more side effects.

Review Question

To help a client reduce his/her anxiety level, the nursing priority would be to:

1. Teach relaxation exercises.

2. Involve the client in unit activities.

3. Encourage 1:1 interaction with peers.

4. Encourage the client to acknowledge and discuss feelings.

Review Question

The nurse is finding it difficult to listen to a client’s expression of pain, fear, anger, and other feelings. The nurse must focus on:

1. Listening attentively and with concern.

2. Providing quick and ready answers.

3. Giving advice.

4. Changing the subject to a more positive one.

Resources

http://www.adaa.orgThe Anxiety Disorders Association of America (ADAA) is a national nonprofit organization dedicated to the prevention, treatment, and cure of anxiety disorders and to improving the lives of all people who suffer from them.

http://www.isst-d.orgThe International Society for the Study of Trauma and Dissociation is a professional association organized to develop and promote comprehensive, clinically effective, and empirically based resources and responses to trauma and dissociation.

http://www.ncptsd.va.gov/ncmain/informationThe National Center for Posttraumatic Stress Disorder Information Center provides information to interested individuals, including veterans and their family members.

Resources

http://www.socialphobia.orgThe Social Phobia/Social Anxiety Association site offers further links to topics such as current news, treatment, and local group availability.

Kneisl, C.R., Trigoboff, E. (2009). Contemporary psychiatric-mental health nursing. Anxiety and Dissociative Disorder (2nd ed.) (pp. 443-477). Upper Saddle River, NJ: Pearson Education.