Module 2
Chapter 10: Trauma and Stress related disorders
Stress
-Eustress: good stress
-Distress: bad stress
Bad responses in stress can lead to distress, which can cause lack of sleep and bad eating habits, resulting in health issues
Stress - Anxiety (amount of anxiety results in coping) - Relief Behaviors - Effective or Ineffective Medication
Reduction
Diversions, Rest, Physical Activity, Support Systems
Prolonged stress
Asthma, Stomach Ulcers, Eczema and other skin conditions, Heart Disease, Cancer, Depression, PTSD, Colds and Flu
Stress Signaling System
Alertness is Heightened, Circulating Adrenaline= Increased BP, HR, RR, Blood Flow
Brain Signals Hypothalamus
Stimulates Autonomic Nervous System
SNS Signals Adrenal Glands
Epinephrine (adrenaline) is released
Pituitary gland releases ACTH
Same signs as hypoxia
Fight or Flight: Sympathetic Nervous System
Rest and Digest: Parasympathetic Nervous System (common sense and reasoning)
-Epinephrine: subsides when the threat passes
-Hypothalamus: stimulates HPA axis
-Corticotropic Releasing Hormone: travels to pituitary gland
-Acetylcholine: travels to adrenal gland
-Cortisol is released
*When one of the chemicals are imbalanced, depression can occur. Along with manic, psychotic, etc.
Psychotherapeutic Treatment
Cognitive Behavioral Therapy CBT
Selective Serotonin Reuptake Inhibitors SSRI (Anti-depressants)
Group therapy with others who have trauma
Family Therapy
-Can give SSRI for PTSD (First line medications for PTSD)
Prazosin (minipress): antihypertensive, alpha blocker. Lowers vitals and mood so patient can rest
Psychopharmacology
Nightmares: prazosin (minipress)
Panic Attacks: antidepressants, MAOIs, Benzodiazepines
Intrusive Experiences: SSRI antidepressants, second gen antipsychotics
Benzos: Daytime anxiety
Sedative Hypnotic: for sleep
Compassion Stress and Fatigue
Healthcare workers are vulnerable to compassion stress and fatigue
-Overwhelmed
-Dread Working
-Depression
-Mentally and Physically Exhausted
-Difficulty separating work from personal life
Nurses and Staff at riskā¦
Hospice Care
Peds
ER
Oncology
Forensic Nursing
Psych Nursing
Social Worker
PTSD
Posttraumatic Stress Disorder
After a traumatic event outside of range of normal experience
HPA= abnormal
Major Depression frequently occurs
Nightmares, reliving the scenario
Common Elements: helplessness or powerlessness
-Flashbacks
-Alterations in mood and cognition
-Increased Arousal
TBI
Traumatic Brain Injury
High percentage of veterans suffer from TBI
Athletes
Victims of shaken baby syndrome
Alzhiemerās patients
If untreated, can result in permanent disability and brain damage
ASD
Acute Stress Disorder
Witnessing or experiencing a violent or gruesome death of or by an inmate
-Out of body, out of mind: Disassociation
Resolves within 1 month
Dissociative Fugue: accompanied by travel
PTSD v ASD
-Similarities: same triggers,, some/similar manifestations
Differences: only ASD resolves within 1 month
Chapter 11: Anxiety, Disorders, Obsessive-Compulsive, Related Disorders
Anxiety v Fear
Fear: Reaction to specific danger
Anxiety: results from real or perceived threat
-Normal Anxiety: healthy life force necessary for survival
-Acute: precipitated by imminent loss or threat
-Pathological: disturbances in a persons ability to function
-Chronic: long-term, young age, increased risk for cardiovascular morbidity
Levels: Mild, Moderate, Severe, Panic
Mild to Moderate: perceptual field, decreased ability to learn
Severe to panic: narrow pinpoint perpetual field, cannot learn, strong emotions and behavior traits
Defense Mechanisms: automatic psychological processes that protect the individual against anxiety and internal/external dangers
-Sublimation: unacceptable impulses transformed into socially acceptable behavior
-Humor: making bad events into jokes
-Suppression: going away from problems and emotions
-Compensation: making up for a lack of something
-Introjection: make other opinions/ideas your own. You are how you are raised
-Repression: sit on emotions and thoughts
-Displacement: projecting bad emotions given to you onto someone else
-Reaction formation: ātell you what you want to hearā
-Somatization: converting stressor into something painful. Conversion involves the senses
-Undoing: hurting someone and buying something or being extra nice to make up for it
-Rationalization: occurs in the head. Try to justify behaviors
-Regression: revert back to what you done as a child, how you cope and deal with things
-Projection: think people want to do to you what you want to do to them
-Denial: ignoring reality of situation to avoid anxiety
Panic Disorders (PD)
panic attacks
same sign as heart attack
Phobias
persistent, irrational fear of something
social phobia: agoraphobia
Gradual desensitization to help patient overcome the fear
General Anxiety Disorders (GAD)
severe distress with pervasive cognitive dysfunction and impaired functioning
Anxiety due to Medical Conditions
Resp, Cardiovascular, Endocrine, Neurologic, Metabolic
Social Anxiety Disorders (SAD)
anxiety provokes by exposure to a social or performance situation
Fear of public speaking
Obsessive Compulsive Disorder (OCD)
Obsessions are unwanted thoughts
Compulsions are unwanted behaviors
Exists along a continuum, DSM diagnostic disease
Body Dysmorphia Disorder (BDD)
imagined ādefectiveā body part
obsessional thinking about the body
Compulsive Hoarding
excessive collection of items considered worthless
extreme life disruption and distress
social isolation
Unsafe living conditions
50% hoarding patients exhibit OCD
-Highly Co-occuring: substance abuse, MOD
-Frequently Co-occuring: ED, BD, Dysthymia
-Chronic Anxiety: Increased risk for cardiovascular morbidity
Burnout: exhaustion caused by long-term involvement in emotionally demanding situations
Compassion fatigue: cumulative physical, emotional, and psychological effect of working closely with those suffering from consequences of heart wrenching, traumatic events.
Meds
-Benzodiazepines (anxiolytics): short term tx only, not for patients with substance abuse
-Buspirone: management of anxiety disorders, non addictive
-SSRIs: first line tx for AD, OCD, and BDD
-SNRIs: PD, GAD, SAD
-Tricyclic antidepressants: 2nd or 3rd line use for PD, GAD, SAD
clomipramine is effective in OCD
-MAOIs: reserved for tx resistant conditions due to risk of life-threatening hypersensitive crisis, SAD and rejection sensitivity
Chapter 12: Somatic Symptom Disorder and Dissociative Disorder
-Somatize: tendency to experience and communicate physical symptoms in response to psychological distress
No evidence of medical condition found
Abnormal thoughts, feelings, and reactions
-Dissociation: daydream, āzone outā, fantasize (all healthy)
Trauma= Dissociative Identity Disorder
Mental Detachment
Somatic Symptom Disorder
persistent preoccupation with and distress over physical symptoms
symptoms of anxiety
increased healthcare use
Theory
20% first degree female relatives
Early trauma, school stressors, etc
Rejection from significant other
Clinical Picture
pain as predominant symptom
Persistent: mild, moderate, severe
Illness Anxiety Disorder
Illness preoccupation with or without mild symptoms
High anxiety over health
Conversion Disorder
presents with impaired motor or sensory function complaint
Findings inconsistent with known neurologic conditions
Lack of concern or high distress
Co-morbidities: child abuse, depression, anxiety, personality disorder
Factitious Disorder
-Imposed on self: patient identifies as impaired or ill
single or recurrent episodes
-Imposed on others: usually parent/caregiver
*Fabrication of symptoms or self-inflicted injury
*Malingering: faking injury for obvious gain
Somatic is seen in medical clinics not psych because symptoms present as primarily physical in nature
Diagnosis for SSD: Ineffective Coping
Assess for
secondary gains (benefits derived from injury)
Dependence on medications (typically benzodiazepines)
>Often become dependent on pain, sleep, and anxiety meds
Prescribe anxiolytic agents
Often return for Rx refill
Dissociative Disorders
-Depersonalization/Derealization: Recurrent periods of feeling unreal, detached, out of body, numb
Symptoms not related to medical conditions or substance abuse
-DID
2+ personality traits that control behavior
each alter has own pattern of emotions and memories
Severe sexual, physical, and psychological trauma can cause DID
-Dissociative Amnesia
Psychologically induced memory loss and inability to recall important personal information after severe trauma
-Dissociative Amnesia with Fugue
Sudden, unexpected travel from a customary locale, and the inability to recall ones identity after traumatic event
Chapter 13: Personality Disorders
Major mental illnesses: bipolar disorder, schizophrenia, depression
-Blaming: genuinely unaware that their personality traits are causing the problems
PD: personality disorder
Personality traits are exaggerated and rigid to the point that they cause dysfunction in relationships
50% or more who come for med advice have a PD
Emotional, social, and occupational disability
No single cause, combination of hereditary and temperamental traits
Childhood neglect is damaging
Borderline PD: BPD
Native and African Americans, young adults, low socioeconomic, divorced, widowed, never been married
Cluster A Disorders: precursors to schizophrenia
āoddā or eccentric, unusual beliefs
Avoid interpersonal relationships
*Schizotypal PD
resembles schizophrenia, no psychosis (losing touch with reality)
*Paranoid PD
pervasive, persistent, inappropriate suspicions and distrust of others for no reason
*Schizoid Personality
Flat affect, Little energy to relationships
Cluster B Disorders
Emotional reactivity, poor impulse control, manipulation
Unclear sense of identity
*Antisocial PD
disregard for others, entitlement, impulsiveness
*Borderline PD
Unstable
90% end in suicide
Splitting, emotional lability
*Narcissistic PD
Entitlement, Lack of empathy, envious of others
Narcy Nurse: only cares about looking good with skills and using them on patients but does not care for the patients themselves
*Histrionic PD
Manipulative , Insensitive, Sexual actions, Dramatic
Center of attention, short-lived relationships
Cluster C Disorders
High anxiety and outward signs of fear
Inhibited, internalizing blame
*Avoidant PD
Low self-worth, hypersensitive, Avoids going out
cannot keep relationships with a job or vice versa
*OCPD
Perfectionist, Stingy, High Achiever, Stubborn
*Dependent PD
Inability to survive if alone
Excess need to be taken care of
Excessively submissive, Tolerant of poor and abusive relationships
Cannot make own decisions without excess reassurance
Primitive Defenses
Attempts to control inner chaos
Exhibit outrageous and troublesome behaviors
Blurred personal boundaries
Managing Behaviors
Assess patient for period of time before labeling as manipulative
Set limits on behaviors and always document the behaviors
Provide clear boundaries and consequences, enforce the consequences
Avoid: talking about self, promising to keep secrets, accepting gifts, doing special favors
Therapy
CBT: cognitive behavioral therapy, changes thoughts and actions
Psychotherapy
Psychodynamic Psychotherapy
Dialectical Behavior Therapy: stabilize the patient, achieve behavior control, effective in helping patient gain hope and quality of life
Pharmacologic
Meds arenāt available to treat PD, but are available to treat the symptoms
Benzos are Not appropriate
Meds with LOW toxicity
-SSRI: co-morbid depression and panic
-Trazodone and venlafaxine: low toxicity in overdose
-Carbamazepine: targets impulsivity and self-harm
-Lithium, anticonvulsants, SSRIs: minimize aggression
-Atypical antipsychotics: psychotic features in BPD under stress
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