Stress/coping and anxiety disorders notes

Stress & Coping

Stress Definition

Stress is defined as:

• An internal or external event or demand experienced by an individual.

• It is perceived and appraised for scope and meaning.

• This appraisal determines if resources are available, exceeded, or exhausted for management.

A stressor is any event or stimulus that disrupts a person's sense of equilibrium.

Stress appraisal is the process by which a person interprets a stressor as either a threat or a challenge.

Coping

Coping involves dynamic cognitive and behavioral efforts to manage demands, whether internal or external. These demands are appraised as exceeding immediately available resources.

Distress is negative stress, while eustress is positive stress.

Types of Stress

• Physiologic Stress: The body's potentially harmful reaction to a stimulus.

• Psychological Stress: The emotional and cognitive factors involved in appraising a threat.

• Sociocultural Stress: Stress when social systems are challenged by racism, economic hardship, or political upheaval.

Autonomic Nervous System (ANS) - Fight or Flight

The autonomic nervous system mediates the body's fight-or-flight response:

• A survival mechanism to meet threats or stress.

• The sympathetic nervous system (SNS) signals the adrenal glands to release epinephrine and norepinephrine.

• This results in increased blood pressure, heart rate, and respiratory rate, increasing blood flow to the brain.

The rest and digest system connects the central nervous system (CNS) to limbs and organs, acting as a relay between the brain and spinal cord.

General Adaptation Syndrome (GAS)

GAS is the physical response to stress and involves a stress signaling system:

1. The brain signals the hypothalamus.

2. The hypothalamus stimulates the autonomic nervous system.

3. The pituitary gland releases ACTH.

4. SNS signals adrenal glands.

5. Epinephrine (Adrenalin) is released.

6. Resulting in:

   • Heightened alertness

   • Increased heart rate, blood pressure, and respirations

   • Increased blood flow

The body prepares for a situation that threatens survival.

Hypothalamus-Pituitary-Adrenal (HPA) Glands

In chronic stress:

• The hypothalamus stimulates the HPA axis.

• Corticotropic-releasing hormone (CRH) travels to the pituitary gland.

• The pituitary gland releases Acetylcholine (ACh).

• ACh travels to the adrenal glands, and cortisol is released.

When stress is prolonged, chemicals produced by the stress response (cortisol, adrenaline, and other catecholamines) can have damaging effects on the body.

Cortisol is considered the body's main stress hormone.

Maladaptive Coping

Maladaptive coping is defined by:

• Inability to accurately assess the stressor.

• Denial or avoidance.

• Actual or perceived lack of control.

• Actual or perceived lack of support.

• No experience or poor past experiences in managing stressful situations.

Assessment of Maladaptive Coping

Assessment involves examining the person and the situation to determine the individual’s appraisal stage and coping strategies by using the following methods:

• History

• Perception of threat

• Past coping patterns

• Medical history

• Social history

• Examination

• Observation of behavior

• Mental health assessment

Coping Strategies Assessment:

• Use open-ended questions.

• Identify the patient’s ability to problem-solve.

• Tailor coping strategies to the individual.

• Cultural competence is essential.

• Address both physical and psychological manifestations of stress.

• Check all systems for physical signs of stress.

• Stressors for one person are not necessarily stressors for another.

Safe Practice Alert: Verbalization of suicidal ideation or a suicide plan must be taken seriously; if the patient is hospitalized, one-on-one observation should be implemented to ensure patient safety and referral to psychiatric services should also be implemented. Do not leave the patient alone.

Types of Coping

• Problem-focused coping: uses cognitive processes to manage or change the stressor, focusing on eliminating or reducing the cause.

• Emotion-focused coping: regulates the emotional response to the situation, focusing on controlling the emotional response rather than eliminating the stressor.

• Meaning-focused coping: uses values, beliefs, and goals to modify the personal interpretation and response to the problem.

Interrelated Concepts

Stress is highly interrelated to coping, as coping is a stress response. Stress and coping can be viewed as having an equal but different effect on an individual. Coping is how the individual views and addresses the stressor.

Stress-Reduction Techniques

• Eliciting the relaxation response

• Physical activity

• Social supports

• Sleep, guided imagery, meditation, biofeedback, yoga

• Reframing

Coping and Defense Mechanisms

Coping minimizes stress and can be problem-focused or emotion-focused. Long-term coping strategies that use defense mechanisms can prevent healthy growth and development.

Defense mechanisms are predominantly unconscious, protective coping methods in response to a perceived threat. They are a response to stress and anxiety and can prevent harm on a short-term basis.

To determine if defense mechanisms are adaptive (healthy) or maladaptive (unhealthy), assess the degree of distortion from reality and disruption in interpersonal relationships.

Defense Mechanisms

• Compensation: Focusing on strengths rather than perceived weaknesses.

• Conversion: Converting stress and psychological symptoms into physical symptoms.

• Denial: Ignoring aspects of reality that induce anxiety or contribute to a loss of self-esteem.

• Displacement: Redirecting negative emotions perceived as unacceptable or threatening to a safer focus.

• Intellectualization: Overthinking a challenging situation or impulse to avoid dealing with the emotions it elicits.

• Projection: Attributing one’s own motives, values, desires, situational responses, and personality traits to another person.

• Rationalization: Explaining personal actions in a way that enhances one’s own self-image.

• Regression: Reverting to behavior associated with an earlier stage of development when challenged by thoughts and stressors.

• Repression: Blocking unacceptable thoughts and feelings from consciousness.

• Reaction Formation: Responding to negative thoughts or feelings by demonstrating opposite emotions and actions.

• Sublimation: Rechanneling unacceptable impulses into socially acceptable activities.

Recognizing Maladaptive Coping

Assessment involves examining the person and the situation to determine the individual’s appraisal stage and coping strategies through:

• History

• Perception of threat

• Past coping patterns

• Medical history

• Social history

• Examination

• Observation of behavior

• Mental health assessment

Stress-Related Disorders

Post-Traumatic Stress Disorder (PTSD)

Usually occurs after a traumatic event outside the range of usual human experience. Major depression frequently occurs. If left untreated or undertreated, painful repercussions can result.

Examples of traumatic events:

• Childhood physical abuse, torture, or kidnapping; military combat; sexual assault; natural disasters; human disasters

• Crime-related events: terror attacks, assault, mugging, rape, incest, taken hostage

• Diagnosis of a life-threatening illness

PTSD Symptoms

• Flashbacks

• Avoidance of stimuli associated with trauma

• Experience of persistent numbing of responses

• Persistent symptoms of increased arousal

Pharmacology for Target Symptoms of PTSD

• Depression: Antidepressants

• Intrusive experiences: SSRI antidepressant, atypical antipsychotics

• Treatment-resistant PTSD: Atypical antipsychotic, AED

• Panic attacks: Antidepressants, monoamine oxidase inhibitors (MAOIs), benzodiazepines

• Hyperarousal: Antidepressants, benzodiazepines, AED

• Nightmares: Prazosin (Minipress)

Compassion Fatigue

Compassion fatigue is different from burnout which relates to emotional exhaustion and withdrawal associated with an increased workload and institutional stress.

Compassion fatigue describes the emotional effect that nurses and other health care workers may experience by being indirectly traumatized when helping or trying to help a person who has experienced primary traumatic stress.

Areas in which nurses and other staff are at risk:

• Hospice care

• Pediatrics

• Emergency Departments (EDs)

• Oncology

• Forensic nursing

• Psychiatric nursing

• Social workers who work closely with traumatized individuals

Symptoms include feeling overwhelmed, physically and mentally exhausted, interference with the ability to function, intrusive thoughts/images, difficulty separating work from personal life, becoming pessimistic, critical, irritable, prone to anger, or dread of working with certain individuals.

Other symptoms include:

• Depression

• Ineffective and/or destructive self-soothing behaviors

• Withdrawing socially and becoming emotionally disconnected from others

• Becoming demoralized, questioning one’s professional competence and effectiveness

• Becoming easily frustrated

• Insomnia

• Lowered self-esteem in nonprofessional situations

• Loss of hope

Compassion Fatigue Levels of Anxiety

Implementation and Evaluation

• Focus on decreasing stressors and improving coping strategies.

• Interventions need to be agreed on by the patient and the nurse.

Strategies

• Internal: Address patient’s feelings associated with stress.

• External: Provide relief through mobilization of support.

• General: Implementing evidence based practices.

Anxiety Disorders

• Panic disorder (PD)

• PD with agoraphobia (fear of public/open spaces)

• Phobia

• Social anxiety disorder (SAD) or social phobia

• Generalized anxiety disorder (GAD)

• Anxiety caused by a medical condition

• Obsessive-compulsive disorder (OCD)

• Post-traumatic stress disorder and acute distress disorder

Panic Disorders

Panic disorders consist of recurrent and unexpected panic attacks. A panic attack involves the sudden onset of extreme apprehension or fear, usually associated with feelings of impending doom. Panic attacks can happen at any time, and people experiencing panic attacks may believe that they are losing their minds or are having a heart attack. Panic attacks have an 18% higher rate of suicide attempts.

Panic Attack Symptoms

• Feelings of terror

• Suspension of normal function

• Severely limited perceptual field

• Misinterpretation of reality

• Sudden occurrence of panic attacks

• Increased rates of suicide and suicide attempts

• Palpitations

• Chest pain

• Diaphoresis

• Muscle tension

• Urinary frequency

• Hyperventilation, breathing difficulties

• Feelings of choking

• Chills, hot flashes

• Gastrointestinal distress

Panic Disorder Medications

• Treatment of choice is Benzodiazepines for acute issues

  • Lorazepam (Ativan)

    • Increased sedation

    • Hypotension

    • Avoid ETOH

    • Antidote: Flumazenil (Romazicon)

• SSRIs for long-term prevention

  • Sertraline (Zoloft)

    • Weight gain

    • Sexual dysfunction (ED)

    • Hypotension

    • Black Box Warning: Suicidal ideations

    • Serotonin Syndrome as a result of taking SSRIs.

    • Discontinuation of the drug must be done slowly,

    • Flu-like symptoms

• Specific phobia: Irrational fear of a specific object, activity, or situation

• Social phobias or social anxiety disorder: Anxiety with exposure to a social or performance situation; fear of public speaking is the most common

• Agoraphobia: Excessive anxiety or fear about being in a place or situation from which help might not be available and escape might be difficult

Acute anxiety: Benzodiazepines; Long-term treatment of anxiety: SSRIs

Generalized Anxiety Disorder (GAD)

Characterized by excessive, persistent, and uncomfortable anxiety, and by excessive worrying; referred to as “the worried disease.” The individual’s worry is out of proportion to the actual situation and can affect disturbances in relationships and impairment in functioning at work.

GAD differs from anxiety disorders because patients do not fear a specific external object or situation, and there is no distinct symptomatic reaction pattern.

Obsessive-Compulsive Disorder (OCD)

• Obsessions: Unwanted, intrusive, persistent ideas, thoughts, impulses, or images that cause significant anxiety or distress

• Compulsions: Unwanted, repetitive behavior patterns or mental acts intended to reduce anxiety but not to provide pleasure or gratification

OCD behavior exists along a continuum; compulsion temporarily lowers the anxiety. Individuals may experience mild obsessive-compulsive behaviors.

More severe symptoms center on dirtiness, contamination, and germs, with corresponding compulsions such as cleaning and hand washing; the most severe symptoms include persistent thoughts of sexuality, violence, illness, and death.

Body Dysmorphic Disorder

• Obsessive thinking with an imagined defective body part(s)

• Feelings of shame

• Co-occurring with major depression, substance use disorder and social phobia

• Higher rate of suicide

Hoarding Behaviors with OCD

• Excessively collects items and exhibits a failure to discard items

• Approximately 50% of patients who exhibit hoarding have co-occurring OCD.

• Associated with increased comorbidity, impairment in performing activities of daily living (ADLs), reduced insight, and poor response to treatment as well genetic and neurobiological profile.

Hoarding Behaviors without OCD

• Exhibits compulsive and disabling hoarding. Results in social isolation, but no extreme disruption occurs in the performance of ADLs.

• Has difficulty discarding possessions, strong urges to save items, and exhibits distress when discarding items.

• Accumulation results in clutter and interventions of third parties are staged.

Medications Used in Anxiety Disorders

• Anxiolytic

  • Buspirone (Buspar)

    • Multi time dosing throughout the day- cumulative effect and no dependency issue

• Antidepressant

  • Tricyclic Antidepressants (TCAs) Amitriptyline

    • Second or third line due to side effects

• β-Blockers [Antihypertensive]

  • Atenolol (Tenormin) B1 (Beta 1)

    • blocks epinephrine effect on heart & blood vessels, Off-label use for short-term acute anxiety.

  • Propranolol (Inderal) B2 (Beta 2)

    • inhibits sympathetic stimulation of the heart and the lungs, Off-label use for short-term acute anxiety.

• Benzodiazepines

• SSRIs

• SNRIs

• TCAS

• Β-Blockers

Management

• Medications with the psychotherapeutic treatments

• Anxiety disorder patients are mostly treated as outpatient.

• When hospital admission is necessary for severe anxiety or symptoms:

  • Milieu Therapy can be helpful:

    • This structures the daily routine to offer physical safety and predictability thus reducing anxiety.

    • Providing daily activities to promote sharing and cooperation.

    • Providing therapeutic interactions, including one-on-one nursing care Behavior contracts and including the patient in decisions about his or her own care.

  • Psychotherapeutic Treatment

    • Cognitive behavioral therapy (CBT)

      • teaching to restructure their thinking

    • Behavioral therapy such as role modeling

      • systematic desensitization, and thought stopping

    • Group therapy with others who have had traumatic experiences

    • Family therapy