NUR 330 Week 5/GAD, OCD, stress and defense

stress

natural part of life

Stress (Acute or Chronic) and can cause overload to allostasis
• Stress have negative mental and physical health consequences (ACE study)

homeostasis

the body’s tendency to resist physiologic change and hold bodily functions
consistently

allostasis

how the body adapts to maintain physiological stability using the autonomic nervous
system, hypothalamic-pituitary-adrenal (HPA) axis, cardio-vascular, metabolic, immune systems -->
this can lead to stress if long term

hypothalamic pituitary adrenal (HPA) axis

Connects the brain and the endocrine system to regulate how body responds to stress

Alarm sounds: acute threat: Amygdala (in brain) signals Hypothalamus
◦ Hypothalamus (in brain): releases corticotropin releasing hormone
◦ Pituitary (below brain): releases adrenocorticotropin hormone
◦ Adrenal glands (on kidneys): releases cortisol, the primary stress hormone
◦ Cortisol release: increases blood glucose, helps maintain heart rate, improves alertness and response times in acute stress

acute stress

fight or flight

chronic stress

wear and tear” on the body

general adaptation syndrome

how the
body responds and adapts to stress,
understanding HPA
◦ Adapted by Hans Seyle
◦ HPA (hypothalamic-pituitary-adrenal)
◦ Excessive exposure to cortisol contributes
to the dysregulation of the autonomic
nervous system

transactional stress model

primary appraisal- what does this mean to me, is it a threat

secondary appraisal- do i have the ability and tools to deal with this

coping- problem focused= change the situation, emotion focused=regulate

reappraisal- after coping they will assess, can be beneficial or not

problem-focused coping

“What can I do?”
◦ Address source of stress to solve issue
◦ Used when a stressor is in a person’s
control
◦ Long term stress reduction
Examples
◦ Making a plan
◦ Time management
◦ Setting boundaries

emotion-focused coping

“How can I handle how I feel?”
◦ Address stress by reinterpreting
situation to change its meaning
◦ Used when a stressor is out of a
person’s control
Examples
◦ Mindfulness
◦ Journaling
◦ Positive affirmations
◦ Religious practices

overall goals of nursing care for stress

1.if possible, resolve the stressful person–environment situation
2. reduce the physiological and psychological stress response
3. develop positive coping skills

nursing interventions for stress

Support healthy behaviors
• Nutrition
• Exercise
• Self care
• Relaxation techniques
• Make them attainable/realistic for
each person

defense mechanism

Unconscious, automatic
to deny or distort
reality and avoid
painful emotions
◦ Usually maladaptive but
can be adaptive

coping mechanism

Conscious, intentional
to manage stress and
regulate emotions
◦ Can be adaptive or
maladaptive

adaptive coping mechanisms

Healthy and constructive
• Reduces stress and promotes well-being
• Examples: exercise, good diet, counseling, using social
networks

maladaptive coping

Unhealthy, short-term fixes
• Interfere with quality of life and relationships
• Examples: procrastination, substance misuse, compulsive
behaviors, anger, outbursts, obsessive thoughts

acting out

using actions rather than reflections or feelings during emotional conflict

denial

refusing to acknowledge some painful aspect of external reality or subjective experience that would be apparent to others

displacement

transferring a feeling about, or a response to, one object onto another

dissociation

experiencing a breakdown in the usually integral functions of consciousness, memory, perception of self or the environment

humor

emphasizing the amusing or ironic aspects of the conflict or stressor

intellectualization

excessive use of abstract thinking or the making of generalizations to control or minimize disturbing feelings

passive aggression

indirectly and unassertively expressing aggression toward others

projection

falsely attributing to another one’s own unacceptable feelings

rationalization

concealing the true motivations for one’s own thoughts, actions, or feelings through the elaboration of reassuring or self-serving but incorrect explanations

repression

expelling disturbing wishes, thoughts, or experience from conscious awareness

splitting

compartmentalizing opposite affect states and failing to integrate the positive and negative qualities of the self or others into cohesive images

sublimation

channeling potentially maladaptive feelings or impulses into socially acceptable behavior

suppression

intentionally avoiding thinking about disturbing problems, wishes, feelings, experiences

altruism

dealing with anxiety by reaching out to others

displacement

shifting feelings related to an object, person, or situation to another less threatening object, person, situation

anxiety

Uncomfortable feeling of apprehension or dread in response to
internal or external stimuli
• Physical, affective, cognitive, and behavioral symptoms

determining normal vs abnormal anxiety

Intensity and duration of anxiety relative to situation
• Trigger for anxiety
• Symptom clusters are distressing, interfere with life

Generalized anxiety disorder

uncontrollable, excessive worry for the majority of days over at least 6 months

significant impairment in areas of functioning

manifestations of GAD

restlessness

muscle tension

avoidance of stressful activities or events

increased time or effort required to prepare for stressful activities

procrastination in decision making

sleep disturbance

panic disorder

Extreme, overwhelming form of anxiety, often experienced when an individual is
placed in a real or perceived life-threatening situation includes:

1. recurrent unexpected panic attacks

2. At least one panic attack has been followed by 1 month (or more) of one or both of the
   following:
   • Persistent concern or worry about additional panic attacks or their consequences.
   • A significant maladaptive change in behavior related to the attacks
   3. The disturbance is not attributable to the physiologic effects of a substance
   4. The disturbance is not better explained by another mental disorder

recurrent unexpected panic attacks

abrupt surge of intense fear or
intense discomfort that reaches a peak within minutes, lasts approx. 15-30 min, and during
which time four (or more) symptoms occur (involves physical and cognitive symptoms)
◦ Physical: palpitations, SOB, chest pain, choking sensation, nausea
◦ Cognitive/thought/perceptual: depersonalization, derealization, disorganized thinking, irrational
fears, difficulty communicating

agoraphobia

Fear or anxiety triggered by situations
such as using public transportation,
being in open spaces, being in
enclosed places, standing in line,
being in a crowd, or being outside of
the home alone

panic attack assessment

What were you doing when the panic
attack occurred?
• What did you experience before and during
the panic episode, including physical
symptoms, feelings, and thoughts?
• When did you begin to feel that way? How
long did it last?
• What do you do when you have these
experiences to help you to feel safe?
• Have the feelings and sensations ever gone
away on their own?

MH and wellness goals for anxiety and panic

Developing a healthy lifestyle
▪ Supporting self-efficacy,
accomplishment and control
 daily schedule
 time to relax/reset, avoid
multitasking
 coping skills
▪ Reducing anxiety and panic

emergency care for acute anxiety/panic

Stay with the patient
❖Reassure them that you will not leave
❖Give clear, concise directions
❖Walk or pace with the patient
❖Assist the patient in an environment with minimal stimulation
❖Administer PRN anxiolytic medications
❖Afterward, allow the patient to discuss their feelings
❖HELP, PROMPT, WAIT de-escalation techniqu

panic control treatment

Involves intentional exposure to panic-inducing sensations
(e.g., dizziness, tight chest).
• Practice relaxation, breathing techniques, cognitive
restructuring to adapt and manage responses

implosive therapy

Therapist presents vivid anxiety-provoking imagery to
desensitize.
• Flooding: Repeated exposure to feared objects or situations
until anxiety decreases (e.g., exposure to snakes)

medication management for anxiety disorders

antidepressants- SSRIs (FIRST LINE), SNRIs

benzodiazepines- lorazepam, alprazolam

atypical anxiolytic/nonbarbiturate- buspirone

beta blockers- propranolol

peripherally acting antiadrenergics- prazosin

obessions

Excessive, unwanted, intrusive, and persistent thoughts, impulses, or
images causing anxiety and distress
◦ Not under the patient’s control; incongruent with the patient’s usual
thought patterns
◦ Irrational, arises from fear/anxiety

compulsions

Repeatedly performed behaviors in a ritualistic fashion (rituals)
◦ Goal is to prevent or relieve the anxiety and distress caused by
obsessions (however, it is ineffective)

diagnostic criteria OCD

Patient recognition that thoughts and actions are unreasonable
or excessive
• Thoughts and rituals causing severe disturbance in daily
routines, relationships or occupational function
• Time consuming - taking longer than 1 hour a day to complete
• Symptoms last at least 2 weeks
• The disturbance is not better explained by the symptoms of
another mental disorder

etiology of OCD

genetic- Occurs more often if immediate family (first degree relatives) with OCD or
Tourette Syndrome

neuropathology- Excessive activity in the frontal cortex and subcortical structures of the brain that correlate with clinical symptoms and cognition and brain function

neurochemical- serotonin levels

excoriation disorder

Skin-picking disorder
◦ Prevalence varies from 1.4% to 5.4%
◦ Behavioral and pharmacologic interventions

body dysmorphic disorder

Focus on real (but slight) or imagined defects in appearance
◦ Extremely debilitating disorder and can significantly impair an individual's quality of life
◦ CBT is the primary treatment approach
◦ Occurs in men and women
◦ The risk of depression, suicide ideation, and suicide is high
◦ High risk for coexisting eating disorder

trichotillomania

Chronic self-destructive hair pulling that results in noticeable hair loss

psychosocial assessment OCD disorders

Mental Status and Appearance
◦ Often normal rate/volume of speech,
but ruminative and obsessive
◦ Circumstantial/circumferential speech

nursing interventions for OCD

establishing recovery and wellness goals

enhancing Cognitive Functioning/Cognitive Restructuring- Restructures dysfunctional thoughts (challenge and restructure the thought)
• Alters immediate appraisals and long-term
perceptions (“right-size” fear)

Exposure and Response Prevention (ERP)- Exposes triggers; prevents ritual responses.
• Reduces anxiety and disrupts expected
outcomes.

Acceptance and Commitment Therapy- Focuses on accepting thoughts/anxiety
without interference.
• Improves function without altering symptoms.
• Useful for post-ERP/CBT relapse.

behavior interventions for OCD

Initially allow rituals
◦ Establish routines
◦ Balance private and social time
◦ Avoid increase of frustration
◦ Encourage discussions
◦ Identify triggers
◦ Self-talk and cognitive restructuring

medication management for OCDs

Antidepressant medication: SSRI & TCA at much higher doses

A successful response to drug treatment = a reduction in the baseline score on a
standardized instrument.
Treatment resistance = there is a minimal/ absent response to treatment.
A refractory response = there has been no response to a trial of two or more
SSRIs.