Mental Health Anxiety/bipolar/somatoform/defense Mechanisms

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Chronic Anxiety

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is anxiety that the person has lived with for a time. According to the ego psychologists suggests that in a nurturing environment the developing personality incorporates the primary caregiver’s positive attributes, which allows the child to tolerate anxiety.

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The child may become anxiety ridden, a state that often covers up what?

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overwhelming, angry, and hostile impulses

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Levels of Anxiety. Mild

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occurs in the normal everyday living.

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Levels of Aniexty: Moderate

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As anxiety escalates, the perceptual field narrows, and some details are excluded from observation.

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Levels of aniexty: Severe

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the perceptual field is greatly reduced. The person may focus on one particular detail or many scattered details.

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Panic Levels of Anxiety

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Is the most extreme form and results in markedly disturbed behavior. The person is not able to process what is going on in the environment and may lose touch with reality.

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Defense mechanisms protect the person from what?

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painful awareness of feeling and memories that can provoke overwhelming anxiety

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Adaptive use of defense mechanisms help people to achieve what?

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to lower anxiety so one can achieve goals in acceptable ways.

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When do defense mechanisms operate?

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Operates all the time. However, when the individual is faced with situations that triggers high anxiety, the person may become more rigid in the use of defense mechanisms and may revert to using less mature defenses

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Vaillant summarized five of the most important properties of defense mechanisms, which are?

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1. Defenses are major means of managing CONFLICT and AFFECT.
2. Defenses are relatively unconscious.
3. Defenses are discrete from one another.
4. Although defenses are often the hallmarks of major psychiatric syndromes, they are reversible.
5. Defenses are adaptive as well as pathological

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What two defenses can NOT be used in both healthy and not so healthy ways?

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sublimination and altruism

these two are always healthy coping mechanisms.

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Alturism

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person recieves gratification either vicariously or from the response of others. Ex. 6 mths after losing husband in car accident, provided grief counseling with families-then getting pleasure from helping people through their pain.

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Sublimnation

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unconscious process of subsituting constructive and socially acceptable activity for strong impulses that are not acceptable in their orginal form. Often these impluses are sexual or aggressive. Ex. Man with strong hostile feelings becomes a butcher or play rough sports.

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Humor

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person deals with the emotional stressors by focusing on the amusing or ironic aspects of the conflict or stressor through humor.

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Supression

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CONSCIOUS denial of a disturbing situation or feeling.
"I can't worry about paying rent until after me exam."

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Most healthy defenses (4):

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altruism, sublimation, humor, suppression

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Intermediate defenses (6):

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repression,
displacement,
reaction formation,
somatization,
undoing,
rationalization

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Repression

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exculsion of unpleasant or unwanted experiences, emotions, or ideas from conscious awareness. Considered the cornerstone of the defense mechanisms and the 1st line of psychological defense against anxiety.

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displacement

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transfer of emotions assoc. with a particular person, object, or situation to another person, object, or situation that is nonthreatening.
Ex. boss yells at man, man yells at wife, wife yells at kid, kid kicks cat.

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reaction formation

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aka "overcompensation", unacceptable feelings or behaviors are kept out of awareness by developing the opposite behavior or emotion.
Ex. a person who harbors hatred towards kids becomes a Boy Scout leader.

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somatization

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Transforming anxiety on an unconscious level into a physical symptom that has no organic cause. Often the symptom functions as an attention getter or excuse.

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undoing

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this makes up for an act or communication. Ex. Giving a gift to undo an argument. A common example of undoing is compulsive hand washing= thought as cleansing oneself of an act or thought that is unacceptable.

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rationalization

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justifying illogical or unreasonable ideas, actions, or feelings by developing acceptable explanations that satisfy the teller as well as the listener. "Everybody cheats, so why shouldn't I"

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Immature defenses (8)

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passive aggresion
acting out
dissociation
devaluation
idealization
splitting
projection
denial

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Passive aggresion

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person deals with emotional conflict or stressors by indirectly and unassertively expressing aggresion toward others. On the surface there is an appearance of compliance that masks covert resistance, resentment, and hostility. Ex. acts of failure, delay, or illness effect others more than oneself.

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acting out behaviors

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responds to stressors or emotional conflicts with actions rather than reflections or feelings.
This is a destructive coping style.
Ex. lashing out anger distracts the self from threatening thoughts and makes the person temporarily feel less vulnerable.

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dissociation

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a disruption in the usually integrated functions of consciousness, memory, identity, or perception of the environment.
Ex. mom saw her son get killed and says " I don't remember what happened."

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devaluation

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stressors or emotional conflicts are dealt with by attributing negative qualities to self or others. When devaluing another, the individual hen appears good by contrast.

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idealization

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stressors are dealt with by attributing exaggerated postive qualities to others. When you do this in a relationship, you are sure to be disappointed and lowers self esteem. when the object/person turns out to be human

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splitting

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inability to integrate good and bad attributes together. Aspects of self and others tend to alternate opposite poles.
Seen in people with personality disorders, esp. borderline ones.

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projection

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Hallmark for blaming or scapegoating
People who always feel othesr are out to get them or cheat them are projecting onto others those characteristics in themselves they find distasteful and can not consciously accept.
Often happens with children, "Tommy is the problem".

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denial

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escaping unpleasant realities by ignoring their existence.

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Why do people use defenses?

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Defenses are a major means of managing conflict and affect, defenses are relatively unconscious, defenses are discrete from one another, they are reversible, and defenses are adaptive as well as pathological.

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Does boiology predispose individuals to pathological anxiety?

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There is no longer any doubt that biological correlates predispose some individuals to pathological anxiety states (e.g., phobias, panic attacks). By the same token, traumatic life events, psychosocial factors, and socio-cultural factors are etiologically significant.

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Genetic Correlates

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Numerous studies substantiate that anxiety disorders tend to run in families, e.g. OCD, phobias, panic disorders, and GAD.

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Explain the role of benzodiazepines in anxiety in the biology theory.

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benzodiazepine receptors are linked to a receptor that inhibits the activity of neurotransmitter GABA. The release of GABA slows neural transmission, which has a calming effect. Binding of the benzodiazepine medications to the benzodiazepine receptors facilitates the action of GABA (Brown, 2003). This theory proposes that abnormalities of these benzodiazepine receptors may lead to unregulated anxiety levels.

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Freud taught that anxiety resulted from?

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the threatened breakthrough of repressed ideas or emotions from the unconscious into consciousness. He also suggested that ego defenses are used by the individual to keep anxiety at a manageable level.

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Sullivan's theory of anxiety

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Anxiety is linked either to the emotional distress caused when early needs go unmet or to the anxiety transmitted to the infant from the caregiver thru the process of empathy. Thus, the anxiety experienced early in life becomes the prototype for that experience when unpleasant events occur later in life.

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Learning Theories of anxiety

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it is a learned response that can be unlearned. Individuals may learn to be anxious from the modeling provided by parents or peers.

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Cognitive theories of anxiety

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take the position that anxiety disorders are caused by distortions in an individual’s thinking and perceiving. Because individuals with such distortions believe that any mistake they make will have catastrophic results, they experience acute anxiety.

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One cultural difference of anxiety

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in cultures individual’s may express anxiety thru the body in others thru the mind

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The term anxiety disorders refer to a number of disorders, including the following:

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Panic, phobias, OCD, GAD, PTSD, ASD, Anxiety due to substance use and abuse, due to medical conditions, and not otherwise specified.

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The panic attack is the key feature of

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panic disorder

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Panic disorder w/o agoraphobia is characterized by

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recurrent unexpected panic attack, about which the individual is persistently concerned

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A panic attack is

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the sudden onset of extreme apprehension of fear, usually associated with feelings of impending doom. The feelings of terror present during panic attack are so severe that normal functions is suspended, the perceptual field is severely limited, and misinterpretation of reality may occur.

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People experiencing panic attacks may believe that they are losing their minds or are having a heart attack. The attacks are often accompanied by what?

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physical symptoms, such as feeling of choking, chills, breathing difficulties, palpitations, and chest pain. Typically panic attacks come “out of the blue,” are extremely intense, last matter of minutes, and then subside.

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Panic disorder with Agoraphobia

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is a combination of physical symptoms, such as feeling of choking, chills, breathing difficulties, palpitations, and chest pain symptoms with agoraphobia.

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Agoraphobia

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is intense, excessive anxiety or fear about being in places or situations from which escape might be difficult or embarrassing, or in which help might not be available if a panic attack occurred (APA, 2000). The feared places are avoided by the individual in an effort to control anxiety. Some people are unable to leave home because of the intense fear they experience being outside.

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Phobias

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a persistent, irrational fear of a specific object, activity, or situation that leads to a desire for avoidance, or actual avoidance, for the object, activity or situations.

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Specific Phobias are characterized by

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are characterized by the experience of high levels of anxiety or fear in response to specific objects or situations, such as dogs, spiders, heights, storms, blood, closed spaces, etc.

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Social Phobia or Social Anxiety Disorder

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is characterized by severe anxiety or fear provoked by exposure to a social situation or a performance situation (e.g., fear of not being able to answer questions in a classroom, eating in public, and performing on stage). Characteristically, phobic individuals experience overwhelming and crippling anxiety when they are faced with the object or situation provoking the phobia. Phobic people go to great length to avoid the feared object or the situation.

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Obsessions

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are thoughts, impulses, or images that persist and recur, they cannot be dismissed from the mind.

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Compulsions

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are ritualistic behaviors that an individual feels driven to perform in an attempt to reduce anxiety. Performing this act reduces the anxiety temporarily; this is why the act is repeated again. Obsessions and compulsions can exist independently of each other, they usually occur together.

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Minor compulsions

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examples such as touching a lucky charm, knocking on wood, and making the sign of cross upon hearing disturbing news, are not harmful to the individual.

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The pathological end of the continuum are obsessive-compulsive symptoms can be:

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that typically involve issues of sexuality, contamination, violence, illness, death. These cause marked distress to the individuals. People often feel humiliated and shame regarding their behaviors. The rituals are time consuming and interfere with daily life.

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Posttraumatic Stress Disorder (PTSD)

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is characterized by repeated reexperiencing of a highly traumatic event that involved actual or threatened death or serious injury to self or others, to which the individual responded with intense fear, helplessness, or horror. It may occur after any traumatic experience. If a person witnesses trauma that means they also experienced the traumatic event.

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Major features of PTSD:

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1. Persistent reexperiencing,
2. Persistent avoidance of stimuli associated with the trauma,
3. experience of persistent numbing of general responsiveness,
4. experiencing of persistent symptoms of increased arousal,
5. Difficulty with interpersonal relationships.

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Feature that almost always accompanies PTSD

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Difficulty with interpersonal relationships

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Persistent reexperiencing of the trauma through recurrent intrusive recollections of the event

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Through dreams and flashbacks (dissociative experiences during which the event is relieved and the event behaves as though he/she is experiencing the event at that time.)

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Persistent avoidance of stimuli associated with the trauma

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Which results in the individual’s avoiding talking about the event or avoiding activities, people, or places that arouse memories of the trauma.

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After trauma, experience of persistent numbing of general responsiveness,

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As evident by the individual’s feeling detached or estranged from others, feeling empty inside, or feeling turned off to others.

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After the trauma, experiencing of persistent symptoms of increased arousal

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As evidenced by irritability, difficulty sleeping, difficulty concentrating, hypervigilance, or exaggerated startle response.

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Difficulty with interpersonal relationships nearly always accompanies PTSD

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trust is a common issues of concern. Child, spousal, chemical abuse are associated with PTSD. It is important for the health care providers to realize that exposure to a stimuli of the original trauma may exacerbate the trauma/symptoms.

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Acute Stress Disorder

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Occurs within 1 month after exposure to a highly traumatic event. To be diagnosed with this the individual must experience at least three dissociative s/s either during or after the trauma: a subjective sense of numbing, detachment, or absence of emotional responsiveness. By definition, it resolves in 4 weeks; if not then the dx changes to PTSD.

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Substance-induced Anxiety disorder

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is characterized by s/s of anxiety, panic attacks, obsessions and compulsions, that develop with use of a substance or within a month or stopping use of the substance.

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Anxiety Due to Medical Conditions s/s

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The individual’s s/s of anxiety are direct physiological result of medical condition, such as hyperthyroidism, pulmonary embolism, or cardiac dysrhythmias

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By having a clear understanding of the emotional pitfalls of working with clients who have anxiety disorders, the nurse is more prepared to

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minimize and avoid guilt associated with strong negative feelings. By examining personal feelings, the nurse is better able to understand their origin and to act objectively and constructively.

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Clients with anxiety disorders use what type of defenses to cope and lessen the anxiety.

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ego defenses

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How do the rituals of an OCD client affect the nurse and their relationship?

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The rituals may frustrate the nurse who is trying to accomplish tasks on time. A nurse that feels anger or frustration may withdraw from the client both emotionally and physically. As a result the client feels anxious and may also withdraw.

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How can the nurse combat the fustrations of working with anxiety pts?

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By having a clear understanding of the emotional pitfalls of working with clients who have anxiety disorders, the nurse is more prepared to minimize and avoid guilt associated with strong negative feelings. By examining personal feelings, the nurse is better able to understand their origin and to act objectively and constructively.

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When is a milieu therapy used for aniexty patients?

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Hospital admissions are necessary only if the anxiety symptoms are severe that interfere with individual’s health, and are suicidal. When hospitalization is necessary, the following features of the therapeutic milieu can be especially helpful to the client.

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What type of interventions are helpful to the anxious client? (5)

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1. Structure the daily routine to offer physical safety and predictability, thus reducing the anxiety over the unknown.
2. Provide daily activities to promote sharing and cooperation. 3. Providing therapeutic interactions, including one-on-one nursing care and behavior contacts.
3. Include the client in decisions about his/her own care.
4. Promote self care activities.
5. Teach clients relaxation techniques such as warm baths, warm milk, etc.) b/c physical exhaustion may occur because of severe anxiety and rituals

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How does the nurse promote self care activities to an anxieous client?

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If they are severely anxious or engage in rituals may not be able to take the time to eat or groom. Some phobic clients may be afraid of the germs that they cannot eat. Provide nutritious snacks. Also, when severely anxious they may not be able to follow directions so give them simple, one sentence instructions, such as “Put your shirt on.”

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Psychobiological Interventions for anxiety

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Psychopharmacology-Antidepressants such as SSRIs are the first line of tx for anxiety disorders. MAOIs are reserved for tx resistant conditions b/c of risk of HTN crisis. Venlafaxine (Effexor) is an SNRI that is also useful for tx of anxiety disorders.

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Psychopharmacology:
Antidepressants have the secondary benefits of treating comorbid depressive disorders in clients. However, there are three notes of caution:

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1. When tx is started, low doses of SSRIs must be used because of the activating effect, which temporarily increases anxiety symptoms.
2. In clients with co-occurring bipolar disorders, use of an antidepressant may cause a manic episode, which requires the addition of mood stabilizers or even antipsychotic agents.
3. MAOI's are contraindicated for clients with comorbid substance abuse b/c of risk of HTN crisis with use of stimulant drugs.

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Antidepressants have the secondary benefits of treating comorbid depressive disorders in clients. However, there are three notes of caution when administering:

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1. low doses of SSRIs b/c of the activating effect, which temporarily increases anxiety symptoms. 2 clients with co-occurring bipolar disorders, use of an antidepressant may cause a manic episode, which requires the addition of mood stabilizers or even antipsychotic agents

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Use of MAOIs is contraindicated in clients with comorbid substance abuse because

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of the risk of hypertensive crisis with use of stimulant drugs.

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Anxiolytics: Benzodiazepines:

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The neurotransmitter GABA seems to have an inhibitory effect on neurons in many parts of the brain. Drugs that can enhance this effect exert a sedative-hypnotic action on brain function. The most commonly used anxiolytic agents are the benzodiazepines.

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Types of benzodiazepines

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Diazepam (Valium), clonazepam (Klonopin), and Alprazolam (Xanax)

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Action of Benzodiazepines

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bind to specific receptors adjacent to the GABA receptors. Because of their ability to bind benzodiazepines, these receptors are called benzodiazepine receptors. Binding of benzodiazepines to these receptors at the same time that GABA binds to its receptors allows GABA to inhibit more forcefully than it would if binding alone.

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What about benzodiazepines limit the potential for toxcity

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The fact that benzodiazepines do not inhibit neurons in the absence of GABA

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What benzodiazepines have a predominately hypnotic effect

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Flurazepam (Dalmane) and Triazolam (Halcion)

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What benzodiazepines reduce anxiety without being a soporific (sleep producing)

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Lorazepam (Ativan) and Alprazolam. There seems to be some evidence that there are subtypes of the benzodiazepine receptors in different areas of the brain, and these subtypes differ in their ability to bind the different drugs.

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What accounts for benzodiazpines efficacy as anticonvulsants and their ability to reduce the neuronal overexcitement of alcohol withdrawal.

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The fact that the benzodiazepines potentiate the ability of GABA to inhibit neurons

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Benzodiazapines used alone

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When used alone, even at high dosages, these drugs rarely inhibit the brain to the degree that respiratory depression, coma, and death results.

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When benzodiazapines combined with other central nervous system (CNS) depressants, such as alcohol, opiates, or TCAs…

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the inhibitory actions of the benzodiazepines can lead to life-threatening respiratory depression. Any drug that inhibits electrical activity in the brain can interfere with motor ability, attention, and judgment. A client taking benzodiazepines must be cautioned about engaging in activities that could be dangerous if reflexes and attention are impaired.

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a drug that reduces anxiety w/o having strong sedative-hypnotic properties

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• NON-Benzodiazepine-Buspirone (Buspar)

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Buspar is not a CNS depressant and thus does not…

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"does not leave a great danger of interaction with other CNS depressants such as alcohol. Also, there is no potential for addiction that exists with benzodiazepines.

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Somatoform Disorders

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Physical s/s suggest a physical disorder for which there is no demonstrable base. There is a strong presumption that the symptoms are linked to psychobiological factors. The nurse needs to recognize that in somatoform disorders symptoms are not intentional or under conscious control of the client, unlike in malingering or factitious disorders.

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Somatoform Disorders vs. Malingering

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Malingering involves a conscious process of intentionally producing symptoms for an obvious environmental goal, e.g., and employee c/o back pain to get disability income.

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Factitious Disorder

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deliberate fabrication of symptoms or self-inflicted injury with the goal of assuming the sick role; e.g., injecting saliva under the skin to form an abscess

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Most common factitious disorder

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Munchausen Syndrome by Proxy is the most common and most severe factitious disorder, in which a caregiver injures a victim to get attention or sympathy for himself or herself.

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The somatoform disorders are also differentiated from psychosomatic illness, in which there is evidence of a general medical condition that may be

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affected by stress or psychological factors (e.g. ulcerative colitis or essential HTN).

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Somatoform Disorders include the following:

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Somatization disorder,
conversion disorder,
pain disorder,
hypochondriasis,
body dysmorphic disorder.

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What is theroized to lead to Somatoform Disorder

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It is theorized that structural and functional abnormalities of the brain may lead to somatoform disorders. Serotonin and norepnephrine are closely involved in depression and anxiety; but they are also critical components of the internal pain-modulating system.

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somatization disorders and genetics..how do they relate?

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SD tends to run in families, occurring in 10%-20% of first-degree female relatives of women with somatization disorders.

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Psychocosial Factors: Psychoanalytic theories-

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are related to repression and conflict. E.g., in conversion disorder, conversion symptoms allow a forbidden wish or urge to be partly expressed but sufficiently disguised so that the individual does not have to face the unacceptable wish to communicate a need for special treatment or consideration from others.

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Hypochondriasis

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is considered by many clinicians to have psychodynamic origins. Anger, aggression, and hostility that had its source in the past losses or disappointments is expressed as a need for help and concern from others. In body dysmorphic disorder, according to some theorists, the individual invests a part of the body with special meaning that may be traceable to some event that occurred at an earlier stage of psychosexual development.

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How does hypochondriasis come out?

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The original event is repressed and the attachment of special meaning to a part of the body comes about thru symbolization. Projection is used when the individual makes statements such as “it makes everyone look at me with horror.”

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Behavioral theories-somatoform symptoms

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are learned ways to communicate helplessness and they allow individual to manipulate others.

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Cognitive theories- sd

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the client focuses on body sensations, misinterprets their meaning, and then becomes excessively alarmed by them.

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Somatization Disorder: most frequent s/s

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1. pain (head, chest, back, joints, pelvis),
2. dysphagia,
3. nausea,
4. bloating,
5. constipation,
6. palpitations
7. dizziness.
These clients seek out multiple providers.

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Hypochondriasis-misinterpret simplest physical sensations as evidence of

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a serious illness.

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Pain Disorder

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when discomfort leads to significant impairment, pain disorder is diagnosed.

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Body Dysmorphic Disorder

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usually have normal appearance. Preoccupied with an imagined defective body parts results in obsessional thinking and compulsive behavior such as mirror checking and camouflages. May have multiple plastic surgeries.

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Conversion Disorder

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Most common somatoform disorder = conversion disorder.

marked by the presence of deficits in voluntary motor or sensory functions. Common symptoms are involuntary movements, seizures, paralysis, abnormal gait, anesthesia, blindness, and deafness. Most common somatoform disorder.

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Assessment of Somatoform

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1. Assessment should begin with collection of data about the nature, location, onset, character, and duration of the symptoms.
2. Assess the ability if they can meet their basic needs.
3. Assess if the symptoms are under the voluntary control of the client. Identify the secondary gains the client may be receiving from the symptoms.
4. Assess how the client perceives physical stimuli, if they are distorting reality. The client may have a difficulty communicating the emotional needs. Often become dependant on meds.

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Assessment/ interventions of Somatoform

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Nurses may find themselves angry, especially if the client uses symptoms to manipulate the staff. Observe and point the behavior. Observe if the symptoms are occurring with anything specific. Setting goals that have staged outcomes (small, attainable steps)-helps the nurse avoid helplessness.

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For Disscociative clients, consciousness itself is altered in a

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dramatic way, whereas thinking, feeling, and perceptions are less impaired.

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Biological Factors

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Current evidence suggests that the LIMBIC system is involved in the development of dissociative disorders. Traumatic memories are processed in the limbic system, and the hyppocampus stores this information.

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Genetic Factors

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several studies suggest that Dissociative Identity Disorder (DID) (used to be multiple persoanlity disorder) is more common among 1st degree biological relatives of individuals with the disorder than in the population at large.

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Psychosocial Factors

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Learning theory suggests that dissociative disorders can be explained as learned methods for avoiding stress and anxiety. The pattern of avoidance occurs when the individual deals with an unpleasant event by consciously deciding not to think about it.

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Dissociative Disorders: psychosocial factors

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The more anxiety provoking the event, the greater the need not to think about it. The more this technique is used, the more likely it is to become automatically invoked as dissociation. When stress is intolerable-e.g., in an abused child-the individual develops dissociation to defend against pain and the memory of it.

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The person experiencing depersonalization may feel

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mechanical, dreamy, or detached from the body. These experiences of feeling a sense of deadness of the body, of seeing oneself from a distance, or of perceiving the limbs to be larger or smaller than normal are described by clients as being very disturbing.

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Depersonalization Disorder

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persistent or recurrent alteration in the perception of the self while reality testing remains intact.

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Dissociative Amnesia

1. General amnesia=Unable to recall information about his/her entire life (3) selective=The client is able to recall some events but not all events in a certain period

2. Localized=The clients unable to remember all events in a certain period

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is marked by the inability to recall important personal information, often of a traumatic or stressful nature, that is too pervasive to be explained by ordinary forgetfulness. A client with generalized amnesia is unable to recall (?). The amnesia may also be localized (?) or selective (?)

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Dissociative Fugue

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is characterized by sudden, unexpected travel away from the customary locale and inability to recall one’s identity and information about some or all of the past. After a few weeks or months they may remember their former identities and become amnesic for the time spent in the fugue state.

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Dissociative Identity Dissorder (DID)

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the presence of two or more distinct personality states that recurrently take control of behavior. Each personality is a complex unit with its own memories, behaviors, and social relationships that dictate how the person acts when that personality dominates. It is believed that DID occurs in individuals who have been severely abused physically or sexually.

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Consider the following when assessing memory:

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1. Can the client remember recent and past events?
2. Is the memory clear and complete or partial and fuzzy?
3. Is the client aware of the gaps, such as lack of memory for events as graduation or wedding?
4. Do the client’s memory place the self with family, school, or occupation?
5. Question about recent injuries. Hx of seizures, especially temporal lobe seizures. Hx. of early trauma. Is the individual depressed, anxious?

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Assessment: of DID

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Question about substance abuse. Has the client’s function been impaired. Also assess the suicide risk.

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DID Planning and interventions is influenced by the

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by the setting and presenting problem.
1. Offer emotional presence during the recall or painful experiences
2. providing a sense of safety
3. encouraging an optimal level of functioning.
**During hospitalization safety is a priority**

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Dissociative Disorders: Interventions

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1. Quiet, simple structured, and supportive environment is encouraged.
2. Confusion and noise may increase anxiety and dissociations.
**No specific meds. Antidepressants or anxiolytics may be prescribed. --Substance use disorders and suicide risk, which are common, must be assessed carefully if meds are to be used. --

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Medications for dissociative Disorder

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Antidepressants or anxiolytics may be prescribed. Substance use disorders and suicide risk, which are common, must be assessed carefully if meds are to be used.