Anxiety and Stress Related Disorders

1. ANXIETYDISORDERS Prof Sathish Rajamani

2. AnxietyandRelatedDisorders -Definition:Vague,subjective,nonspecificfeelingof uneasiness, tension,apprehension,&sometimesdreadorimpendingdoom. -Symptoms:hypertension,tachycardia,musclehypertonia, hyperactivity,irritability. www.nursingpath.in 7/16/2019 2

3. -Commondisordersthathaveanxiety symptoms: 1- NeuroticDisorders:HystericalDisorder, Depression,PTSD. 2- PsychoticDisorders:Majordepressivedisorder, Schizophrenia. 3- OrganicDisorders:Hyperthyrodism, Athersoclerosis,Hypoglycemia,Post-concussion, Menopause,Pre-menstruation. www.nursingpath.in 7/16/2019 3

4. *Predisposingfactors:(2) 1-Hereditaryfactors: -Averageofanxietyinidenticaltwins:>50%. 2-Age: -AnxietyincreasesinChildren(Immaturenervoussystem). -AnxietyincreasesinElderly(Atrophicnervoussystem). Sxinpediatric:phobiainnight,phobiafromstrangers,animals, olderchildren,beingalone,nightmares,urinalorfecalincontinence, walkingduringsleeping. Sxinadolescent:unsuitability,irritability, socialembarrassmentesp. whenfacingormeetingtheothersex,guiltyfeeling,anxiousabout genitalarea,beingveryshy,speechstutter. SxininAdulthood:DECREASE. Sxininelderly:INCREASE(regardingdz.,death) www.nursingpath.in 7/16/2019 4

5. Typesofanxiety(accordingtolevel) 1.Mildanxiety: a.Physiologic:V/Snormal,minimalmuscle tension,pupilsnormal,constricted. b.Cognitive:perceptualfieldisbroad -Thoughtmayberandombutcontrolled. c.Emotional/Behavioral:relativecomfort&safety, relaxed,calmappearance&voice. **Habitualbehaviorsoccurhere. www.nursingpath.in 7/16/2019 5

6. 2.ModerateAnxiety: a.Physiologic:V/Snormalorslightlyelevated, Tensionexperienced,maybeuncomfortable. b.Cognitive:alert;perceptionnarrowed,focused (Optimumstateforsolving&learning),Attentive. c.Emotional/Behavioral:Readiness&challenge (energize),engageincompetitiveactivity&learn newskills,voice&facialexpressionconcerned. www.nursingpath.in 7/16/2019 6

7. 3.SevereAnxiety:symptoms a.Physiologic:Fightorflight,autonomicN.system excessivelystimulated(highlyincreaseinv/s, diaphoresis,urineurgency&frequency,diarrhea,dry mouth,decreaseappetite,dilatedpupil),musclesrigid, tension,decreaseheating&painsensation. b.Cognitive/perceptual:Perceptualfieldgreatly narrowed,problemsolving:difficult,automaticbehavior, selectiveattention(focusononedetail). c.Emotional/Behavioral:Feelsthreatened,seemorfeel depressed,becomesverydisorganizedorwithdrawn, maycloseeyestoshutoutenvironment. www.nursingpath.in 7/16/2019 7

8. •PanicAttack: Definition:Adiscreteperiodofintensefearordiscomfortin whichfourormoreofthefollowingSxdevelopedabruptlyand reachedapeakwithin10minutes. 1-Palpitations 2-Sweating 3-Tremblingorshaking 4-Sensationsofshortnessofbreath 5-Feelingofshocking 6-Chestpainordiscomfort 7-Nauseaorabdominaldistress 8-Feelingdizzy,unsteadyorFaint 9-Realizationoflosingcontrol 10-Fearofdying 11-Parenthesis 12-Chills orhotflashes www.nursingpath.in 7/16/2019 8

9. 1.Phobias -Pt.experiencespanicattackinresponsetoparticular situationsorlearnstoavoidsituationsthatevokepanic attack. -Phobiaresultsevenpt.knowsthatitwon’thappen&no dangerifexposedtosituation. -Evenpt.knowsthatverywellhe/shecan’tcontrolphobia anddoesn’tconfrontinternalconflictbutconvertitinto externalSx. www.nursingpath.in 7/16/2019 9

10. Typesofphobias: 1-Agoraphobia:Anxietyaboutbeinginplacesor situationsfromwhichescapemaybedifficult(or embarrassing)orinwhichhelpmightnotbereadily availableineventofunexpectedpanicattack. -Thisincludes:fearofbeingalone,beingincrowdedarea orstandinginaline,being,onabridge,travelinginabus; becomesinneedtohaveacompanion. www.nursingpath.in 7/16/2019 10

11. 2-Socialphobia:fearfrombeingunderobservationfrom others,which mayleadtoavoidingsocialneed. -Usuallyaccompaniedwithlowself-esteem(evaluationand fearofcriticism). Course& prognosis: -Usuallystartsinlatechildhood& earlyadolescence. -Maybecomechronic&decreasesaftermidlife. -Rarelythatdisorderissevere&interferewithvocational performancebecauseofavoidance. -Complications: -Addiction(Alcohol,anti-anxiety). -Depression. www.nursingpath.in 7/16/2019 11

12. Rx: 1-Drugs:anti-anxietyoranti-depression. 2-Psychotherapy: Behavioralpsychotherapy:withdrugsinseverecasesby GradualDesensitizationbyexposinghimtothefearobject graduallyandcouldbeaccompaniedbysomedrugsor relaxationtrainingorFlooding:byexposingpt.suddenlyto fearobjectinrealityorimagination. Insightpsychotherapy:Tomakept.understandthecause phobia&secondarygainsymptoms,roleofresistanceand thiswillmakehimabletofindmethodsmoreacceptableto controlanxietywithmotivatingpt.tobeexposedtophobia situation. www.nursingpath.in 7/16/2019 12

13. 3-Simplephobia(isolatedphobia)(specific phobia): -Includesspecifiesconditions: 1-Claustrophobia:Fearofclosedplaces. 2-Mysophobia:fearofdirt,germsandcontamination. 3-Acrophobia:fearofheights. 4-Zoophobia:fearofanimals. 5-Aquaphobia(orhydrophobia):fearofwater. 6-Nectrophobia:fearofdarkness. 7-Pyrophobia:fearoffire. 8-Hematophobia:fearofblood. 9-Necrophobia:fearofdeadbodies. 10-Xenophobia:fearofstrangers. 11-Astrophobia:fearoflightening. www.nursingpath.in 7/16/2019 13

14. Course &prognosis: -Beginningofsimplephobiasisvaried. -Zoophobiastartsinchildhood. -Hematophobiaoftenstartsinadolescenceor earlyadulthood. -Acrophobiaoftenstartsinthe fourthdecade. -Mostofotherphobiasthatstartinchildhood disappearwithouttreatment. -Disabilityresultsfromsimplephobiasisslightif avoidancewaseasyaszoophobia,butdisabilityis increasingifstimulusiscommon,spread&not avoidableasfearofridingcarsforstudent. www.nursingpath.in 7/16/2019 14

15. 2-PostTraumaticStressDisorder(PTSD) -Pt.musthaveexperiencedtraumaticeventprior toonsetofSx. -Pt.mayhaveexperiencedevent,witnessedit,or havebeenconfrontedwitheventthatinvolved actualorthreateneddeathorseriousinjury. -Eventshouldbeoutsiderangeofusualhuman experience. -Pt.response:intensefear,helplessnessorhorror. www.nursingpath.in 7/16/2019 15

16. -Pt.willhaveSxfrom1-3months(Acute)or3-6 months(Chronic) -Eventcausethisdisordercouldbe: 1-Natural:Earthquakes,volcans. 2-Man-made:Rape,Torture. -PTSDcouldhappeninoneindividualormoreamong group. www.nursingpath.in 7/16/2019 16

17. -Pt.willhavethe followingSx: 1-Re-experiencingtheevent: a.Recurrentdreamsof theevent. b.Suddenactingorfeelingasiftraumaticeventwas recurring(includingsenseofre-livingtheexperience, illusions,hallucinations). 2-Persistentavoidanceofstimuliassociatedwith trauma. 3-PersistentSxofincreasedarousal(difficultyto sleep,irritability,concentration). www.nursingpath.in 7/16/2019 17

18. Course& prognosis: -Mayoccurinanyageafterevent(1wk-30yrs). -Sx:fluctuating&becomesevereduringstressfulevents. -AcutePTSDlastsfor<3monthsbutitcouldbecome chronic(>3months). -30%ofpts.withPTSDrecovers,40%slightsymptoms, 20%moderatesymptoms,10%becomeworse. -Prognosisisconditionedby:rapidonset,goodpre-morbid functioning&goodsocialsupport. -Complications:socialphobiadisturbanceinrelationswith othersguiltyfeelingthatmayleadtosuicide. www.nursingpath.in 7/16/2019 18

19. *Rx: 1-Drugs: Tofranil( Imipramine),Inderal(Propanolol). Catapress(Clonidine). 2-Psychotherapy: -Cognitive-behavioralapproach: 1-Buildinggoodrelationshipwithpt. 2-Cognitiveappraisalofevent&explainingtopt. effectofstressonhumanbeing&thatsymptoms areanormaloutcometoanabnormalsituation. www.nursingpath.in 7/16/2019 19

20. 3-Relationtraining&desensitizationbybuildinga hierarchyofstressfulmoments&relaxation. 4-Socialsupport&involvingfamily&friendsincaring &understandingpt.'scondition. www.nursingpath.in 7/16/2019 20

21. 3-AcuteStressDisorder The same condition of PTSD, but the period to hav e the Sx is 2 days-1 month. www.nursingpath.in 7/16/2019 21

22. 4-GeneralizedAnxietyDisorder -Excessiveworry&anxietyabout2or>oflifeconditions: Worryofachildofbeingdyingorexposingtoanyharm(in factnodangeratall). -3ormoreofthefollowingsx will appear: 1-Restlessness 2- Easilyto befatigued 3-Irritability 4- Difficulties inconcentration 5- Muscletension 6- Sleepdisturbances . www.nursingpath.in 7/16/2019 22

23. Prognosis: -May startinanyagebutis >in20s &30s. -Mainlychronic &maycontinueforlife. -Complication:is panicattack. -othercomplication:addictionbecauseofself-treatment. Rx: 1-Drugs:shoulddecreaseprescribedanti-anxietyaspossible (becausedisorderis chronic). 2-Psychotherapy:Rxofchoice. a-Psychoanalyticpsychotherapy:throughlong-terminsight. b-Behavioralpsychotherapy:focusesondesensitizationwith entrancetocognitivetherapyaimstostopconditioningin additiontorelaxation&modifyingbehavior. www.nursingpath.in 7/16/2019 23

24. 5-ObsessiveCompulsiveDisorder 1-Obsession:undesirablebutpersistentthoughtoridea forcedintoconsciousness&can’tbeerasedordismissed, thoughtmaybetrivialormorbid.Alwaysdistressingor anxietyprovoking. 2-Compulsion:unwantedurgetoperformactorritual contrarytopt.'sordinaryconsciouswishesorstandards. -Uncontrolled&donetorelieveextremetension. -Obsessionproducesanxietymanagedbycompulsiveact. 3-Obsessioncompulsion:repetitiveactsorritualstorelease tensionorrelieveanxiety. -Pt.carriesouttheseactsevenifhe recognizesthattheyare inappropriateorfoolish. www.nursingpath.in 7/16/2019 24

25. Examples: a.Endlesshandwashing. b.Checkingre-checkingdoorsifthey'relocked. c.Elaboratedressingrituals. -Pt.istryingtoresistthis,butbecauseoflongperiodof disorder,resistancemaydecrease. -Asaresult,pt.willhavemuchdifficultiesinsocialr/s. -Pt.isneurotic(becausept.believesthattheseideasare nottrue&silly). www.nursingpath.in 7/16/2019 25

26. Course&prognosis: -Usuallystartsinadolescence. -Chronicdisorder&pt.maynotpresenttopsychiatrist for5-10years. -About30%ofpts.:goodimprovement,30-40%:mild improvement,&therest:chronicorworse. -Somepts.mayhavedepression,suicideoraddiction. www.nursingpath.in 7/16/2019 26

27. Rx: 1-Drugs: -Anfranil(Clomipramin):Drug ofchoice(6-12months). 2-Behavioraltherapy: -Effectivein60-70%ofpts.(maybeRx ofchoice). -Techniquesused:Desensitization,thoughtstopping,flooding &implosiontherapy. Aversiveconditioning:meansgivingapainfulshockorloud noisewhenthoughtoccurs. -Someuseresponsepreventingas:forciblystoppingpt.from respondingtoobsession. 3-Psychodynamicpsychoanalytictherapy: -Aimstohelppt.getinsightintohisaggressiveimpulses& strengthensegotodealwithaggressioninmatureways. www.nursingpath.in 7/16/2019 27

28. 6-SomatorormDisorders -Focusingisphysicalsxinabsenceofclinically significantorganicdisease. A-BodyDysmorphicDisorder -Preoccupationwithimagineddefectinappearance. -Slightanomaly:concernisexcessive. -Significantdistressorimpairmentinsocialor occupationalfunctioning. -Preoccupationisnotbetteraccountedforbyanother mentaldisorder. www.nursingpath.in 7/16/2019 28

29. Course&prognosis: -Startsinadolescence,20’sor30’s,staysconstantly& mayhaveresultofsocial&vocationaldisability. -Complication:Plasticsurgerieswithoutanyneed. Rx: -Pts.refusepsychotherapydespitetheirseveresuffering &insistonhavingplasticsurgeriessoitisimportantfor plasticsurgeontoreferthemtopsychiatristor psychologist. -Meds.mayreliefSx (anti-anxiety,anti-depression). -Long-termpsychotherapyisrecommended. www.nursingpath.in 7/16/2019 29

30. B-Paindisorder -Clinicalpresentationofpainin1or>anatomicalsites. -Painisseveretowarrantclinicalattention&causes majorimpairmentin1or>areasoffunctioning. -Psychologicalfactorsplayimportantroleinonset, severityexacerbation,ormaintenanceofpain. -Acute:lessthan6months(duration). -Chronic:morethan6months(duration). Course&prognosis: -Infemaledoublethanmales. -Increaseat4th&5thdecade&b/wpoorpersons. www.nursingpath.in 7/16/2019 30

31. Rx: Drugs:Givinganalgesicsornarcoticsisnotuseful (?addiction). -Anti-depressantcanbegiven:(Elatrol)or(Prozac). -Anxioloticsoranalgesicsusuallynoteffective. Psychotherapy:Importantthattherapisthelpspt. recognizepsychogenicoriginofpain. -Explaintopt.howpersonstateofmindaffectshow muchpainhecanfeel. -Relaxationtechnique,sportsexercice. -Biofeedback. -Sometimes,admissiontohospitalisneededtocontrol feelingofpain(behavioral,cognitive&group psychotherapymaybeused). www.nursingpath.in 7/16/2019 31

32. C- SomatizationDisorder -Frequentlyseeking&obtainingmedicalRxformultiple clinicallysignificantsomaticcomplaints. -Complaintsmustbeginbefore30&cannotbeexplainedby anymedicaldisorderordirecteffectsofsubstance. -Multiplesclerosispt.wouldnotbedxedbysomatization. -Differentiatedfrommedicalconditionsif: -Involvementofmultipleorgansystems(GI,neurological..). -Sxexhibitearlyonset&chroniccourse,without developmentofphysicalsignsorstructuralabnormalities. -Absenceofclinical(laboratory)abnormalities. www.nursingpath.in 7/16/2019 32

33. Course&prognosis: -Females>males. -Lessoccurrenceifhighsocialclass,moreamongpoor &illiteratepersons. -Startsbefore30. -Increaseamongfirst-degreerelatives. -Chronic&pt.israrelyfreeofsxorformedicalseeking. www.nursingpath.in 7/16/2019 33

34. Rx: -Long&empathicr/swithonetherapist. -Usingmeds.isnotrecommendedbutanti-depressant oranxiolyticscanbeusedsymptomaticallyifanxietyor depressionispresent(?addiction). www.nursingpath.in 7/16/2019 34

35. D-ConversionDisorder(Hystericalneurosis, ConversionType): -Lossorchangeinbeadyfunctioningthatcan’tbe explainedbyanymedicaldisorder,&occursinresponse topsychologicalstress. -Infemales>males. -Usuallystartsinadolescenceoryoungadulthood. -Medicalexamsdonotrevealphysicalabnormality. -Pt.isnotconsciousofproducingsx. -Histrionicpersonalitypt:moreexposedthanothers. -Couldhappenifexposedtogreatstress. -Lossorchangecangivesensory/motorsxorboth. www.nursingpath.in 7/16/2019 35

36. Motorsx:Abnormaltremors,jerkymovements. *Note:hystericalconversiontremors:itisirregular& disappearsifattentionmovedtoanothersubject,etc… -Itdiffersfrom tremorinanxiety. -Hystericalaphonia:Pt.can’tspeak,butcanunderstand whatissaid. *Note:todifferentiate,askpt.tocough,ifhedoesso, meansvocalcordsok&ishysterical. www.nursingpath.in 7/16/2019 36

37. Comparisonb/worganic& hystericalparalysis: Tics:involuntarymovementincreasesinembarrassing situations. Hystericalcomas:likenormalsleep,doesn’trespondto stimuli,needscareforurination&defecation,usuallyneeds hospitalization,usedtoescapefromreality. Hystericalfits:differfromorganicepilepsyasfollowing: Sensorysymptoms: Anesthesiaorlossofsensationinapartofbodyoronehalfof body. Hystericaldeafness. Lossofolfactoryortastesenses. Hystericalblindness. www.nursingpath.in 7/16/2019 37

38. Prognosis: -Durationisbrief. -Starts&stopsabruptly. -Tendstorecur. -Prognosisispoorifsecondarygainishigh. *Primarygain:Gainachievedbyconvertinganxietyto somaticsx(symbolicofunconsciousconflict). *Secondarygain:Gainachievedbysx,pt.painrelieved fromworkorgetsattention&sympathyfromfamilyby takingsickrole. www.nursingpath.in 7/16/2019 38

39. Rx: -Excludeorganicdiseasebyphysicalexam. -Psychotherapy: -Tellingpt.thathehasnophysicalproblems&sxare psychologicalstress&willdisappearifpt.expresseshis feelings. -Amytal:maybeusedtoproduceastateofrelaxation& re-experiencetraumawhichenablept.totalkfreely abouthertroubles. www.nursingpath.in 7/16/2019 39

40. E-Hypochondriasis -6majorcriteriaassociatedwithdisorder: 1-Ptispreoccupiedwithfearsofhaving-orideaofhaving seriousmedicaldisorderbasedonhis/herinterpretation. 2-Misinterpretationofbodilysxpersistsdespite appropriatemedicalevaluation&reassurance. 3-Pt’spreoccupationwithSxisnotasintenseor distortedasinbodydysmorphicdisorder. www.nursingpath.in 7/16/2019 40

41. 4-Preoccupationcausesclinicallysignificantdistressor impairmentinsocial,occupational,ormajorareasof functioning. 5-Durationofdisturbanceatleast6 months. 6-Conditionisnotbetteraccountedforbyanother anxietydisorder,somatizationdisorder,ormajor depressiveepisode(Pt.mayshowsxofanxietyor depression). www.nursingpath.in 7/16/2019 41

42. Course&prognosis: -Mostlystartsin20’s. -1/3ofpts.don’timprove&social/vocationdisturbed. -Males&female:equal. Rx: -Excludeanyorganicfactor. -Invasiveprocedureshouldbeavoided. -Psychotherapy:preferredtreatmentevenpt.resiststhis therapy(mayacceptitbyaphysician). -Grouppsychotherapy:Rxofchoice(pt.’ssocialsupport &interactioncanimprovetheircondition). -Drugsnotusedunlessdepression/anxietypresent. www.nursingpath.in 7/16/2019 42

43. Comparisonb/wSomatization& Hypochondriasis Somatization Hypochondriasis 6monthsfordx Lookaboutdisorderbehind sx 7yrsneededfordx Lookaboutsx&Rx C/O13or>sx C/O1or2sx Doesn’tlike Dr.visit Multiple Dr.visit www.nursingpath.in 7/16/2019 43

44. 7-DissociativeDisorders -Disruptioninusuallyintegratedfunctionsofconsciousness, memory,identity&perceptionofenvironment. A.DissociativeAmnesia -1or>episodesofinabilitytorecallimportantpersonal information(traumaticorstressfulnature);tooextensivetobe explainedbyordinaryforgetting. -Disturbancedoesn’toccurduringDissociativeIdentity Disorder. -Notduetosubstanceeffectsorgeneralmedicalcondition. -Mostcommoninfemales. www.nursingpath.in 7/16/2019 44

45. -Usuallypt.isawareofmemoryloss. -Pt.isusuallyalert&notconfused(Somepts.describea stateofcloudedconsciousness). -Onsetissudden&recoveryissudden&complete. -Recurrenceisrare. www.nursingpath.in 7/16/2019 45

46. Rx: -Itisimportanttodifferentiatepsychogenicamnesiafrom organicamnesia(CVA,P.C,etc..). -Amytalinterview:Pt.isgivenshortormediumacting barbituratesasAmytalIV&inastateofalleged consciousnesspt.ishelpedtoremember. -Hypnosis:Underhypnosis,pt.isrelaxed&ina somnolentstateinwhichinhabitationsareweekend,& repressedmemoriescanbereached. -Psychotherapy:Afterrepressedmemoryisreached psychotherapyhelpspt.resolveconflicts. www.nursingpath.in 7/16/2019 46

47. B.DissociativeFugue -Sudden,unexpectedtravelawayfromone’shomeorplaceof work,withinabilitytorecall one’spast. -Confusionaboutpersonalidentityorassumesnewidentity, whichmaybepartial(fillingintheblanks). -Disturbancedoesn’toccurincontextofadissociativeidentity disorder,&isnotduetoeffectsofasubstanceortoageneral medicalcondition. www.nursingpath.in 7/16/2019 47

48. -Whenfugueisover,pt.remembersallhehadforgottenbut forgetswhathappenedduringfugue. -Courseisusuallyshort. -Pt.recoverssuddenly&completelytofindhimselfina strangeplace. -Recurrenceisrare. Rx: -NoRx isrequiredifdurationisshort. -Hyposis&Amytalinterviewmaybeusedtohelppt. rememberhisidentity. www.nursingpath.in 7/16/2019 48

49. C.MultiplePersonalityDisorder(Dissociative IdentityDisorder) -2or>personalities(eachcomplete&integrated). -Atanytime,pt.isdominatedbyonepersonality& unawareofpresenceofotherpersonalities. ->infemales. -Mostlyoccurinadolescenceorearlyadulthood. -Predisposingfactor:severephysical/sexualabusein childhood. -Epilepsyisfoundin25%ofpts. -EEGshowsdifferenceinactivityindifferent personalitiesinthe samept. www.nursingpath.in 7/16/2019 49

50. -Eachpersonalityisintegrated&differinmood,attitude, name,etc… -Usuallyeachpersonalitydoesn’trecognizepresenceof otherpersonalities(Sometimesoneofthemknowsabout theother). -Pt.mayfindhimselfinstrangeplaceorhearingvoices insidehimoranotherpersontakingcontroloverhim. -Chronicdisorder. Prognosis: -Poorifonsetisearly&if>2personalities. www.nursingpath.in 7/16/2019 50