HH/NURS 2547 Week 6: Mental Health & Anxiety

• Week 6 for HH/NURS 2547 6.0 occurring on Feb 12 focuses on mental health across the lifespan.
• Mary Smith, NP, PhD is the Course Director, accessible via [email protected].

Course Updates

• Half of the course is already done
• There is an opportunity to experience York
• There is a second glossary assignment due
• The midterm test is being prepared
• There is a reading week

Anxiety Theme

• Anxiety disorders and epidemiology are key topics
• Generalized anxiety disorder will be covered
• Obsessive Compulsive Disorder will be discussed
• Also, panic disorder
• And somatic and other disorders

Black History Month

• Recognizes and celebrates the legacy, history, and contributions of the Black community
• Celebrates Black excellence and contributions to the university and wider society

Land Acknowledgement

• York University acknowledges its presence on the traditional territory of many Indigenous Nations
• The area of Tkaronto has been cared for by the Anishinabek Nation, the Haudenosaunee Confederacy, and the Huron-Wendat
• It is now home to First Nation, Inuit, and Métis communities
• The Mississaugas of the Credit First Nation are recognized as the current treaty holders
• The Dish with One Spoon Wampum Belt Covenant is an agreement to peaceably share and care for the Great Lakes region

Anxiety - Operationally Defined

• Stress can lead to Anxiety, which in turn can lead to Relief Behaviour
• Stress can be Physical (Environmental, Physical condition), Psychological, Biochemical, Social, and can be real or perceived
• Anxiety can be acute or chronic
• Relief Behaviors include defence mechanism, coping behaviours, and spiritual/cultural/social support

Effective vs Ineffective Mediation

• Effective mediation results in decreased anxiety
• Ineffective Mediation results in Increased anxiety, difficulty coping, extreme use of defences or coping behaviours, precipitation or exacerbation of psychotic symptoms, and chronic unrelieved anxiety

Anxiety Disorders - Epidemiology

• Anxiety disorders are among the most common psychiatric disorders in Canada
• 17% of Canadians reported symptoms in 2020
• Mood and Anxiety Disorders in Canada, 2016 shows an increase in children and youth
• The highest increase is in kids 5-10 years old
• Among those people who menstruate aged 15-24, generalized anxiety disorder tripled from 3.8% in 2012 to 11.9% in 2022

The State of Mental Health in Canada 2024

• Youth across Canada, especially girls/2SLGBTQIA+ youth, are more likely to struggle with mental health and lack services
• Mood disorders affected 9.9% of youth aged 15-24 vs. 6.1% of adults aged 25-44.
• Anxiety disorders affected 12.8% of youth aged 15-24 vs. 7.8% of adults aged 25-44.
• Substance Use Disorder affected 8.5% of youth aged 15-24 vs 5.2% of adults aged 25-44 -The percentage of youth rating their mental health as "poor" or "fair" rose from 12% in 2019 to 26% in 2023.

Role of Nursing

• Why nurses need to prioritize mental health care by nurses

Anxiety Disorders Overview

• Anxiety is driven by excessive fear leading to altered perceptions and behaviour
• It is a key component in several disorders like acute stress disorder, anxiety disorder, anxiety due to medical conditions, depersonalization/derealization disorder, generalized anxiety disorder, obsessive-compulsive disorder, panic disorders, phobias, post traumatic stress disorder, substance induced anxiety disorder and Somatic symptom disorder

Comorbidity

• Anxiety frequently co-occurs with other psychiatric problems
• Anxiety also is frequently seen with depressive disorders
• Treatments for anxiety and other disorders might work due to shared neurobiology, shared symptoms, and abnormalities of emotional processing

Limbic System

• Modulates basic emotions and memory
• Regulates autonomic/endocrine function in response to emotional stimuli and reinforcing behavior
• Comprises several small structures that work in a highly organized way -Includes: hippocampus (storing memories), thalamus (relays sensory information), hypothalamus (basic human activities like sleep patterns, temp and needs), amygdala (brain smell centre)

Amygdala Hijack

• Describes a primitive, overwhelming emotional response
• This response is disproportionate to the actual trigger event

Specific Anxiety Disorders

• Include: Panic disorder, Agoraphobia, Specific phobias, Social phobia, Generalized anxiety disorder, Substance-induced anxiety disorder, Anxiety disorder related to medical condition

Common Phobias

• Acrophobia: Heights
• Agoraphobia: Open spaces
• Apiphobia: Bees
• Astraphobia: Electrical storms
• Claustrophobia: Closed spaces
• Glossophobia: Public speaking
• Hematophobia: Blood
• Hydrophobia: Water
• Monophobia: Being alone
• Mysophobia: Germs or dirt
• Nyctophobia: Darkness
• Pyrophobia: Fire
• Social phobia: Fear of a social or performance situation
• Triskaidekaphobia: Fear of #13
• Zoophobia: Animals

Anxiety Disorders - Assessment Guidelines

• A physical and neurological examination should be performed to determine whether the anxiety is primary or secondary to another psychiatric disorder, medical condition, or substance use
• Assess for substance use, including prescription/nonprescription meds, alcohol, nicotine, and caffeine, as well as illicit substances
• Assess the current level of anxiety – mild, moderate, severe, or panic
• Assess for potential self-harm and suicide
• A psychosocial assessment should be performed
• Ask the patient what is happening in their life that may be contributing to anxiety
• Culture can affect how anxiety is manifested

Common Nonpsychiatric Medical Causes of Anxiety

• Respiratory disorders: chronic obstructive pulmonary disease, pulmonary embolism, asthma, hypoxia, and pulmonary edema.
• Cardiovascular disorders: angina pectoris, arrhythmias, congestive heart failure, hypertension, and hypotension.
• Endocrine disorders: hyperthyroidism, hypoglycemia, pheochromocytoma, carcinoid syndrome, and hypercortisolism.
• Neurological disorders: delirium, essential tremor, complex partial seizures, Parkinson's disease, akathisia, otoneurological disorders, and postconcussion syndrome.
• Metabolic disorders: hypercalcemia, hyperkalemia, hyponatremia, and porphyria.

GAD-7 tool

• Assesses generalized anxiety disorders

Generalized Anxiety Disorder

• Is characterized by excessive anxiety and worry, occurring more days than not for at least six months
• Pertaining to a number of events or activities such as work/school related performances
• Difficulty controlling worry, plus at least three associated physical symptoms

GAD - Cognitive, Physical and Behavioural Symptoms

• Cognitive: "Something's going to go wrong.", "This worry is going to make me sick.", “I need to be sure nothing bad is going to happen."
• Physical: muscle tension, feeling keyed up or on edge, restlessness, irritability, sleep disturbance
• Avoidance of news, newspapers, restricted activities due to excessive worries about what could happen, and excessive reassurance-seeking or over-preparing

Generalized Anxiety Disorder - Treatment

• CBT is considered the first-choice psychological treatment
• It should be offered to all with anxiety disorders
• A brief problem focused on correcting ways of thinking and acting with 12-15 sessions, (individual or group)
• The goal is to identify distortions in thinking, consider different viewpoints and evaluate evidence that supports/doesn’t support fears

Anxiety Medication

• Antidepressants: SSRIs and TCAs
• Other Antidepressants: Venlafaxine XR and duloxetine
• Azapirones: Buspirone + Buspirex
• Benzodiazepines

Anti-Anxiety Medications - Patient and Family Teaching

• Do not increase dose or frequency of ingestion without approval of doctor.
• Be cautious with operating equipment.
• Do not drink alcoholic beverages or take other antianxiety medication.
• Avoid drinking beverages containing caffeine
• When taking Benzos, the patient should avoid becoming pregnant/breastfeeding/monoamine oxidase inhibitors/tyramine restricted diet
• Cessation of benzodiazepines after 3 or 4 months of daily use may cause withdrawal symptoms
• Take medications with or shortly after meals or snacks

Clinical Question

• When prescribed lorazepam (Ativan) 1 mg po qid for 1 week for generalized anxiety disorder, the nurse should teach the patient to limit caffeine intake.

Anxiety disorders-Generic Care Plan - The patient should have:

• Decreased distress immediate with nurse attendance
• Understand triggers for anxiety
• Identify strengths and coping skills

Interventions - Nurse:

• After assessment, administer prescribed medications, monitor and control emotional state

Assessment and Treatment of Anxiety in Older Adults

• Older Adults First Line Treatment: Escitalopram - Selective Serotonin Reuptake Inhibitor (SSRI), Citalopram - Selective Serotonin Reuptake Inhibitor (SSRI), Sertraline - Selective Serotonin Reuptake Inhibitor (SSRI), Venlafaxine - Selective Serotonin Reuptake Inhibitor (SSRI)
• Second Line of Treatment for Older Adults: Duloxetine- Serotonin/Norepinephrine Reuptake Inhibitor
• Third Line of Treatment for Older Adults: Buspirone - GeriMedRisk Drug summary and Infographic coming soon
• NOT Recommended for Older Adults: (only if appropriate circumstances) Quetiapine - Antipsychotic, Pregabalin - Anticonvulsant, Analgesic agent, Lorazepam - Benzodiazepine

Somatic Symptom and Related Disorders

• Soma is the Greek word for the "body"
• Somatization: expression of psychological stress through physical symptoms
• Affects women, men, and children
• Accounts for nearly 25% of primary care clinic visits
• Anxiety, depression, and trauma contribute to these psychological and physical experiences

Somatic Symptom Disorder

• Distressing symptoms
• Maladaptive response
• Without significant physical findings and medical diagnosis
• Suffering is authentic
• High level of functional impairment

Somatic Symptom - Clinical Picture

• Somatic symptom disorder (SSD)
• Illness anxiety disorder (previously hypochondriasis)
• Conversion disorder (also called functional neurological symptom disorder)
• Psychological factors affecting medical condition
• Factitious disorder

Conversion Disorder

• Neurological symptoms in the absence of a neurological diagnosis
• Presence of deficits in voluntary motor or sensory functions
• Includes common symptoms like paralysis, blindness, movement and gait disorders, numbness, paresthesias, loss of vision or hearing, and episodes resembling epilepsy

Factitious Disorders

• Artificially, deliberately, and dramatically fabricate symptoms or self-inflict injury
• Goal of assuming a sick role

Obsessive-Compulsive and Related Disorders

• Obsessions are thoughts, impulses, or images that persist and recur so they cannot be dismissed from the mind.
• Compulsions are ritualistic behaviors an individual feels driven to perform in an attempt to reduce anxiety.

Common Obsessions and Compulsions

• Losing control:
• Fear of acting on an impulse to harm oneself. Compulsion is praying to prevent harm to oneself
• Harm:
• Fear of being responsible for something terrible happening. Compulsion is checking that nothing terrible has happened.
• Perfectionism:
• Need for symmetry; concern about evenness. Compulsion is putting things in order or arranging things until it "feels right"
• Contamination:
• Germs or viruses. The compulsion is washing hands excessively
• Religious Obsessions:
• Concern with offending God. Compulsion is praying to seek forgiveness

Obsessive-Compulsive - Clinical Picture

• Obsessive-compulsive disorder
• Body dysmorphic disorder
• Hoarding disorder
• Hair pulling and skin picking disorders
• Other compulsive disorders

Obsessive Compulsive Disorders - Epidemiology

• Is the fourth most common psychiatric illness
• Typical age of onset is bimodal (10 years and 21 years).
• Earlier onset generally occurs in males
• Childhood OCD is diagnosed almost 3 times often in boys than girls
• Occurs in adults with equal frequency in women and men

Obsessive Compulsive Disorders - Comorbidity

• Commonly co-occurs with other psychiatric conditions with symptoms of rumination (Mood Disorder) and worry (Anxiety Disorder)
• Psychotic disorders may also occur, but people with only OCD are able to recognize that their thoughts are irrational but they cannot control them

Trauma and Stressor-related Disorders

• Includes acute stress disorder
• Also called "PTSD" or "Post-traumatic stress disorder
• There are also dissociative disorders

Acute Stress Disorder

• Occurs within one month of a highly traumatic event that resolves within 4 weeks
• At least 3 dissociative symptoms occur, like a subjective sense of numbing, detachment, or absence of emotional responsiveness
• Plus a reduction in awareness of surroundings
• And a sense of derealization (a sense of unreality related to the environment)
• Plus depersonalization (a sense of unreality or self-estrangement)
• As well as dissociative amnesia

Post-Traumatic Stress Disorder (PTSD)

• New category in the DSM-5 trauma and stressor related disorders
• Is an acute emotional response to a traumatic event or situation involving severe environmental stress
• Involves re-experiencing a traumatic event involving threat or potential for death or severe injury to self/others
• The triggering event or situation is accompanied by intense fear, helplessness, or horror
• It may present after any traumatic event outside the range of usual experience, such as military combat, detention as a prisoner of war, natural disasters, human disasters, crime-related events, or a diagnosis of illness

Post-Traumatic Stress Disorder (PTSD) - Persistent Symptoms

• Persistent re-experiencing the trauma including the event itself
• Dreams about the event
• Flashbacks-dissociative experiences during which the event is relive
• The person behaves as though they are experiencing the event in the present

Stimuli Avoidance

• The patient might also avoid stimuli associated with the trauma
• Which could mean talking about the trauma or avoid activities/people/places that rouse memories of the trauma

Numbing of General Responsiveness

• As evidenced by the person's feeling empty inside or feeling disconnected from others
• Patients can also experience symptoms of arousal
• Evidenced by irritability, difficulty sleeping/concentrating, hypervigilance, or exaggerated startle response

Trauma Question

• The nurse is assessing Mr. Jay who survived a town wildfire. Mr. Jay now feels anxious, has problems sleeping/concentrating, and is fixated on fires - Which is consistent with PTSD

Dissociative Disorders

• Occur after significant adverse experiences or traumas
• Individuals respond to stress with severe interruption of consciousness
• It’s an unconscious defence mechanism
• It Protects individual against overwhelming anxiety through emotional separation

Dissociative Disorders - Clinical Picture

• Depersonalization/derealization disorder
• Dissociative amnesia
• Dissociative identity disorder (DID)

Sleep Wake Disorders

• Includes insomnia disorder, hypersomnia disorder, and confusional arousal disorders

Insomina Disorder

• Is a state of constant arousal and difficulty with sleep initiation, sleep maintenance, early awakening or nonrestorative sleep
• Factors: predisposing, precipitating, and perpetuating

Hypersomnia Disorder

• Is shown by Excessive sleepiness occurring three or more times per week or 3 or more months despite a main sleep lasting 7 hours or longer
• Prolonged nighttime or daytime sleep episode causing significant distress and social or vocational impairment
• Some individuals can sleep up to 20 hours a day
• Narcolepsy: episodes of irresistible attacks of refreshing sleep, muscle weakness, sleep paralysis, waking in a state of temporary paralysis and hallucinations

Confusional arousal disorders

• Recurrent incomplete awakening from sleep with or without a terror or movement, usually during first third of the major sleep episode
• Types include: Sleepwalking, Sleep terrors, Nightmare disorder, Sleep paralysis and Rapid Eye Movement Behavior disorder

Treatment - Sleep-wake

• Sleep hygiene, restriction, stimulus control
• CBT
• Benzodiazepines

Reading Week Week 7

• February 15-21/25
• Midterm Test on Feb 26, 2025
• See Review posted Week 6

Week 6 of HH/NURS 2547 explores mental health across the lifespan, with a special focus on anxiety disorders. Topics include generalized anxiety disorder, obsessive-compulsive disorder, panic disorder and somatic disorders. The lecture also acknowledges Black History Month and York University's presence on Indigenous land.