anxiety, OCD, fear, PTSD

fear

innate intellectual response to a dangerous or life threatening situation, produces anxiety

stress

the pressure that is brought to bear on the individual, can lead to distress or eustress, can be physical or psychological

perception, temperament, support, culture, spirituality/ religious beliefs

factors influencing stress response

mild, moderate, severe, panic

levels of anxiety

mild anxiety

level of anxiety that’s part of day-to-day living, can motivate learning, have increased perceptual field

moderate anxiety

level of anxiety where the focus is only on immediate concern, perception narrows→ selective inattentiveness, decreased clarity of thinking making it harder to learn

severe anxiety

level of anxiety where perceptual field is greatly reduced, either singularly focused or not focused at all, no learning is possible

panic

level of anxiety characterized by awe, dread, terror, fright, or paralyzed, behaviors or not purposeful, unable to process things, possible psychosis

prevent escalation of anxiety, patient can be directed to decrease anxiety, good time to teach

interventions for mild and moderate anxiety

ensure patient safety, decrease stimuli if possible, use firm, short, and concise statements, meds or restraints if other interventions fail, do not prohibit patient from acting on compulsions

interventions for severe anxiety or panic

fight or flight response

body’s way of preparing for a situation someone perceives as a threat, involves sympathetic nervous system, there’s an increase in BP, HR, RR, and CO

alarm, resistance, exhaustion

stages of general adaptation syndrome (GAS)

alarm stage

• stage of GAS that is the initial, brief response to a stressor

• stress→ amygdala activated→ hypothalamus

  • hypothalamus activates adrenal glands to release E→ increases BP, HR, RR, and sharpens all senses

  • hypothalamus releases CRH→ ACTH from pituitary gland→ cortisol from adrenal cortex→ increases BG and muscle endurance

resistance stage

also called adaptation stage, stage of GAS when sustained and optimal resistance to the stressor occurs, stressors are usually overcome, body may transition to 3rd stage if stressors continue

exhaustion stage

stage of GAS that only occurs when attempts to resist the stressor have failed, resources are depleted and stress may become chronic, increases risk of stress-related illnesses

short term effects of stress

uneasiness/ concern, sadness, loss of appetite, suppressed immune system, increased metabolism and use of body fats, infertility, increased energy mobilization and use, increased CV tone, increased cardiopulmonary tone, HTN, increased risk of blood clots and stroke, decreased memory and learning, impotence, anovulation

long term effects of stress

anxiety, panic attacks, MDD, anorexia or overeating, decreased resistance to infections, insulin resistant diabetes, amenorrhea, loss of sex drive, increased fatigue and irritability, increased risk for cardiac events, increased respiratory problems

sources of anxiety disorders

• biological: genetics, imbalance in neurotransmitters

• developmental

• psychological: unconscious conflict between id and superego, classical conditioning, responses are learned/ modeled

• cognitive

defense mechanisms

altruism, conversion, denial, displacement, dissociation, identification, intellectualization, projection, rationalization, regression, repression, reaction formation, sublimation, suppression, splitting, undoing

suppression

what is the only conscious defense mechanism?

displacement

taking out your emotions on someone else

projection

unconscious rejection of emotionally unacceptable features and attributing them to others

intellectualization

analyzing only the facts and not focusing on own feelings

sublimation

transforming negative impulses into less damaging ones

conversion

transforming anxiety into a physical symptom

dissociation

disruption in consciousness, memory, identity, or perception that results in compartmentalizing unpleasant aspects of oneself

reaction formation

when unacceptable feelings/ behaviors are covered up with opposite feeling/ behavior

splitting

inability to integrate positive and negative qualities of oneself/ others into 1 image

undoing

making up for regrettable act

assessment of anxiety disorders

assess for safety, rating scales, history (onset, triggers, duration, pattern, intensity), MSE, level of impact on life/ degree of dysfunction, attempts to cope (+ and -), rule out medical causes

panic disorder

recurrent, unexpected panic attack that peaks within minutes, followed by worry of another attack and/ or maladaptive change in behavior in response to having had a panic attack, intense fear/ terror or feeling of impending doom often associated

4 or more symptoms that have developed and peaked within 10 minutes:

palpitations, sweating, chills or hot flashes, trembling/ shaking, SOB, feeling of choking, chest pain, nausea, dizziness, de-realization or depersonalization, numbing/ tingling sensation, fear of dying, fear of going crazy

DSM5 criteria for panic disorder

separation anxiety disorder

concern of being apart from significant other, fear that something bad will happen to significant other, inability or difficulty functioning for self and significant other, ensure it’s developmentally inappropriate

agoraphobia

fear of going out, fear of being somewhere without chance of escape or help or might be embarrassing, use of avoidance behaviors

social anxiety disorder

severe anxiety triggered by social or performance situation, fear of potentially negative outcomes

excessive anxiety and worry occurring more days than not for at least 6 months, difficult to control their worry, associated with 3 or more symptoms: restlessness/ feeling on edge, easily fatigued, difficulty concentrating, irritability, muscle tension, sleep disturbance

generalized anxiety disorder

obsessive compulsive disorder

anxiety disorder characterized by recurrent obsessions or compulsions that are time consuming or cause significant distress/ impairment, person knows that their obsessions/ compulsions are excessive and unreasonable

obsessions

persistent and intrusive thought, idea, impulse, or image

compulsions

repetitive and seemingly purposeful behaviors performed in response to uncontrollable urges or according to a ritualistic set of rules

body dysmorphia

type of OCD disorder where person has preoccupation with defects of their body, perfectionistic and have fear of rejection, leads to feeling shame, depression, and disgust with self

hoarding disorder

types of OCD disorder where person has accumulation of belongings due to anxiety over getting rid of things, are indecisive and often have depression/ anxiety

trichotillomania

hair pulling, sometime with trichophagia (eating hair)

excoration

skin picking→ damage of skin

relaxation techniques

deep breathing, progressive muscle relaxation, imagery, mindfulness

cognitive distortions

all or nothing thinking, overgeneralization, mental filter, jumping to conclusions, mind reading, labeling, personalization, “should” statements, emotional reasoning, magnification/ minimization

SSRIs, benzodiazepines, buspirone, antihistamines, propranolol, clonidine

drugs to treat anxiety disorders

SSRIs

what’s the first line treatment for anxiety disorders?

benzodiazepines

short term, given in meantime before SSRIs kick in, addicting, need to taper off drug

alprazolam, clonazepam, diazepam, lorazepam, oxazepam, chlordiazepoxide

types of benzodiazepines

acute stress disorder

anxiety disorder that develops during 4 weeks after traumatic event and lasting at least 2 days, diagnosis changes to PTSD after 1 month

symptoms: 3 dissociative symptoms, re-experiences event, avoids situations, intense anxiety, hypervigilance, impairment of everyday functioning

PTSD

occurs for more than 1 month after traumatic event, stress interferes with individual’s ability to function

DSM5 criteria:

• person experienced/ witnesses traumatic event

• response involved intense fear, helplessness, or horror

• trauma is re-experienced through images/thoughts, dreams, flashbacks, and/ or response to cues that symbolize trauma

• avoidance of reminders about trauma, diminished interest/ feelings, feeling detached from others

• increased sensory arousal

stages of treatment for PTSD

1. safety: stop self-destructive behaviors

2. memory work, decreased arousal and dissociation, accepting help and comfort, transforming memories

3. problem solving, develop coping skills, social support

SSRI (sertraline and paroxetine), SNRI (venflaxine), phenelzine or TCA if SSRI ineffective, prazosin, clonidine or propranolol

drugs to treat PTSD

prazosin

drug that’s used to treat nightmares associated with PTSD