Anxiety Disorders PDF

Anxiety disorder Anxiety & Related Disorders Characterized by excessive fear, worry, and physical symptoms (e.g., increased heart rate) that interfere with daily life. Includes generalized anxiety disorder (GAD), panic disorder, social anxiety disorder, and phobias. Obsessive-Compulsive Disorder...

Anxiety disorder Anxiety & Related Disorders Characterized by excessive fear, worry, and physical symptoms (e.g., increased heart rate) that interfere with daily life. Includes generalized anxiety disorder (GAD), panic disorder, social anxiety disorder, and phobias. Obsessive-Compulsive Disorder (OCD) Involves intrusive thoughts (obsessions) and repetitive behaviors (compulsions) aimed at reducing distress, significantly impacting daily life. Somatic Symptom Disorders Physical symptoms without a clear medical cause, leading to excessive health-related anxiety and impaired functioning. Trauma & Stressor-Related Disorders Acute Stress Disorder (ASD): Trauma-related symptoms (flashbacks, anxiety, dissociation) lasting 3 days to 1 month. Post-Traumatic Stress Disorder (PTSD): Persistent trauma symptoms (flashbacks, avoidance, hypervigilance) lasting beyond 1 month. Dissociative Disorders Disruptions in memory, identity, or perception due to trauma. Includes: Dissociative Amnesia: Memory loss of traumatic events. Dissociative Identity Disorder (DID): Two or more distinct personality states. Depersonalization/Derealization Disorder: Feeling detached from self or reality. Concept of Anxiety Anxiety: An uncomfortable feeling of apprehension, dread, uneasiness, or uncertainty. Can stem from real or perceived threats (internal or external stimuli). A subjective response to stress with physical, emotional, cognitive, and behavioral symptoms. Fear vs. Anxiety: Fear is a reaction to a specific danger; anxiety is more generalized. Both trigger the fight-or-flight response. Normal anxiety is essential for survival. Normal vs. Abnormal Anxiety Normal Anxiety: Motivates adaptation and survival. Acute Anxiety: Short-term response to external events (e.g., pre-surgery nerves). Chronic Anxiety: Persistent, unresolved anxiety with maladaptive coping. Panic: Extreme, overwhelming anxiety in real or perceived life-threatening situations. Abnormal Anxiety: When panic occurs frequently or in non-threatening situations. Normal vs. Abnormal Anxiety Anxiety becomes pathological when: No real threat exists. Intensity is excessive. It disrupts roles and responsibilities. It involves flashbacks, obsessions, or compulsions. It impairs daily or social functioning. It persists longer than expected. Levels of Anxiety (Continuum) Mild Anxiety Heightened awareness, focus, and problem-solving ability. Restlessness, slight discomfort. Moderate Anxiety Reduced perception, difficulty concentrating.  Increased heart rate, muscle tension. Severe Anxiety Greatly reduced perception, inability to focus. Dizziness, nausea, hyperventilation. Panic Loss of control, disorientation, terror. Physical symptoms mimic a heart attack. Mild Anxiety Assessment: Alert, aware, no thought distortions. Open to problem-solving and logical thinking. Physical signs: Slight discomfort, restlessness, irritability. Behavioral signs: Tension-relieving behaviors (e.g., fidgeting, nail-biting). Mild Anxiety - Nursing Interventions Stay calm and provide reassurance. Engage in conversation to encourage expression of feelings. Use open-ended questions to facilitate discussion. Practice active listening to validate concerns. Assess past coping strategies and explore effective alternatives. Moderate Anxiety Assessment: Increased anxiety with selective inattention (focus narrows). Problem-solving possible but requires assistance. Thinking becomes less clear. Physical symptoms: Increased tension, restlessness. More extreme tension-relieving behaviors (e.g., pacing, hand-wringing). Moderate Anxiety - Nursing Interventions Goal: Prevent escalation to severe anxiety. Provide 1:1 attention for support and reassurance. Coach deep breathing techniques to promote relaxation. Use simple, clear communication to reduce confusion. Assist with problem-solving to maintain focus. Encourage physical activity and use distraction techniques to redirect energy. Severe Anxiety Assessment: Distorted perceptions, unable to focus. Learning & problem-solving not possible. Intense physical symptoms: Increased somatic complaints (e.g., headache, nausea). May experience hyperventilation or feeling of loss of control. Severe Anxiety - Nursing Interventions Goal: Reduce anxiety to a moderate level. Increase observation due to impaired perception ("tunnel vision"). Reduce environmental stimuli (quiet, calm setting). Focus on the present to ground the client. Administer anxiolytics as prescribed. Role-play deep breathing and grounding techniques. Panic - Assessment Most extreme level of anxiety, overwhelming distress. Loss of touch with reality, possible hallucinations or delusions. Severe psychomotor agitation (pacing, shouting) or complete muteness. Poor reasoning, inattention, unable to process external stimuli. Panic - Nursing Interventions Avoid touch but ensure your presence is known. Stay calm and provide reassurance. Use clear, simple statements to avoid confusion. Reinforce reality to ground the client. Ensure physical safety (prevent self-harm or injury). Administer PRN medications as prescribed and monitor response. Defenses Against Anxiety Defense Mechanisms: Automatic coping strategies. Function: Protect against anxiety, preserve self-image. Mechanism: Block feelings, conflicts, or memories. Types: Can be healthy (adaptive) or unhealthy (maladaptive). Goal: Encourage appropriate defense mechanisms to reduce anxiety effectively. Cognitive Distortions & Anxiety Cognitive distortions contribute to anxiety symptoms. Examples include: Emotional reasoning → Anxiety disorders Catastrophizing → Social anxiety, social phobia, panic disorder Control fallacies → OCD Perfectionism → Anxiety disorders Should/Must statements → OCD Cycle of anxiety and strategies to break it. The key elements include: Anxiety → Triggers physical symptoms. Physical Symptoms → Can be misinterpreted as dangerous. Cognitive Symptoms → Negative thoughts reinforce anxiety. Misinterpretation of Symptoms → Leads to more anxiety, continuing the cycle. Ways to Break the Cycle: ✔ Do the thing you are anxious about → Exposure helps reduce fear. ✔ Challenge the physical symptoms → Recognize them as a normal response. ✔ Normalize & tolerate anxiety → Accept it without avoidance. ✔ Challenge cognitive distortions → Reframe anxious thoughts realistically. Epidemiology & Comorbidity of Anxiety Disorders Prevalence: 11.6% of Canadians ≥18 years experience anxiety disorders. Rising in children & youth, with the highest increase in ages 5-10 years. Higher risk groups: Women, separated/divorced individuals, and survivors of abuse. Comorbidity: 60% of cases co-occur with depressive disorders. Treatment overlap: Similar approaches due to shared neurobiology, symptom similarities, and emotional processing abnormalities. Clinical Picture of Anxiety Disorders Core Feature: Emotional distress is present in all anxiety disorders. Perceived Threat: Individuals feel their identity/personality is threatened, even without real danger. Common Symptoms: Rigid, repetitive, and ineffective behaviors used to manage anxiety. Most Likely to Seek Treatment: Panic Disorder Generalized Anxiety Disorder (GAD) Clinical Picture of Anxiety Disorders Excessive fear leads to altered perceptions and behaviors. Anxiety plays a role in various disorders, including: Acute Stress Disorder Anxiety Disorder (NOS) Anxiety Due to Medical Conditions Depersonalization/Derealization Disorder Generalized Anxiety Disorder (GAD) Obsessive-Compulsive & Related Disorders Panic Disorder Phobias Post-Traumatic Stress Disorder (PTSD) Substance-Induced Anxiety Disorder Somatic Symptom Disorder Etiology of Anxiety Disorders Biological Factors Genetics → Family history increases risk. Neurobiology → Dysregulation of neurotransmitters (e.g., serotonin, GABA, norepinephrine). Social Factors  Traumatic life events → Abuse, loss, or chronic stress. Psychological Factors Psychodynamic Theories → Unresolved unconscious conflicts. Learning Theories → Conditioned responses to fear. Environmental Factors Prenatal toxic exposure → Substance use or stress during pregnancy. Adverse childhood events → Neglect, abuse, or unstable upbringing. Sociocultural Factors Culture-bound syndromes → Anxiety manifests differently across cultures. Panic Disorder Key Feature: Recurrent panic attacks. Diagnostic Criteria: Repeated attacks increasing in duration & intensity over 1-2 months. May or may not be associated with Agoraphobia (fear of situations where escape is difficult). Panic Attack Sudden episodes of intense fear or discomfort, lasting 10-30 minutes. Unpredictable ("out of the blue"). Physical symptoms: Rapid heart rate (tachycardia) Cold sweat Feeling of choking Shortness of breath (SOB) Numbness/tingling (paresthesia) Psychological symptoms: Derealization (feeling unreal) Depersonalization (detachment from self) Fear of dying or losing control Commonly leads to ER visits before a Panic Disorder diagnosis. cycle of anxiety and misinterpretation, showing how anxiety can escalate due to perceived threats and physical/cognitive symptoms. Explanation of the Cycle: Internal or External Trigger → An event, thought, or situation triggers a perceived threat. Perceived Threat → The brain interprets the situation as dangerous, activating anxiety. Anxiety → Leads to physical and cognitive symptoms (e.g., rapid heartbeat, dizziness, racing thoughts). Misinterpretation → These symptoms are wrongly perceived as signs of danger, worsening anxiety. Reinforcement Loop → The misinterpretation feeds back into anxiety, creating a self- sustaining cycle. Breaking the Cycle: ✔ Challenge misinterpretations → Recognize symptoms as part of anxiety, not actual danger. ✔ Manage physical symptoms → Deep breathing, grounding techniques. ✔ Reframe the perceived threat → Shift perspective to reduce anxiety response. Clinical Course of Panic Disorder Lifelong disorder, with peak onset in late teens/early 20s and another peak in the 30s. Chronic condition with periods of exacerbation and remission. Key feature: Disabling panic attacks, which may lead to secondary symptoms like phobias. Comorbidity:  Agoraphobia (most severe, more common in women). Social anxiety disorder (social phobia). Etiology of Panic Disorder Genetic Predisposition: Up to 5x higher risk in first-degree relatives. Fear Network Dysfunction: Involves the amygdala (fear processing) & hippocampus (memory of fear responses). Neurochemical Dysregulation: ↑ Norepinephrine → Heightens physical symptoms of panic. ↓ Serotonin → Implicated in emotional regulation and anxiety control. Psychodynamic & Cognitive-Behavioral Theories of Panic Disorder Psychodynamic Theories: Common background & personality traits → Individuals may be more prone to fearfulness. Childhood factors: Modeling parental behaviors (observing anxious caregivers). Increased separation anxiety → Later manifests as panic in the 20s in response to stress. Cognitive-Behavioral Theories: Fear response is learned → Anxiety develops through conditioning. Catastrophic interpretation → Exaggerating normal sensations as life-threatening. Misinterpretation of physical sensations → Perceiving mild symptoms (e.g., increased heart rate) as a panic attack, reinforcing fear. Risk Factors for Panic Disorder Family History → Higher risk in first-degree relatives. Substance & Stimulant Use/Abuse → Caffeine, nicotine, drugs can trigger panic attacks. Severe Stressors → Major life changes, trauma, or chronic stress. Genetic Predisposition → Inherited vulnerability. Female Gender → Higher prevalence in women. Childhood Trauma → Physical or sexual abuse increases risk. Nursing Management: Biological Domain Assessment: ✔ Self-Assessment → Evaluate personal biases and reactions to anxiety. ✔ Rule Out Other Disorders → Ensure symptoms are not due to medical conditions. ✔ General Symptom Assessment → Use rating scales for severity. ✔ Review Events Before Attack → Identify triggers or patterns. ✔ Substance Use → Assess for stimulants (caffeine, nicotine, drugs). ✔ Sleep Patterns → Evaluate for sleep disturbances. ✔ Physical Activity → Assess for activity levels and exercise habits. Nursing Diagnoses (Table 12-11) Anxiety Ineffective Coping Sleep Disturbance Risk for Self-Harm Impaired Social Interaction Nursing Interventions: Biological Domain ✔ Breathing Control → Helps reduce hyperventilation, interrupts a panic attack, requires practice. ✔ Nutritional Planning → Prevent hypoglycemia, reduce caffeine intake (can trigger anxiety). ✔ Relaxation Techniques → Progressive muscle relaxation, guided imagery, meditation. (get out of their own head) Psychopharmacologic Treatment for Panic Disorder Antidepressants (First-line treatment) SSRIs → Paroxetine, Sertraline SNRIs → Duloxetine, Venlafaxine TCAs (Less common) Anxiolytics (Short-term use) Benzodiazepines → Alprazolam, Lorazepam Beta Blockers (For Performance Anxiety) Propranolol Teaching Points: ✔ Avoid OTC medications (may interact). ✔ Be aware of sedative effects (risk of drowsiness, impaired alertness). ✔ Avoid alcohol (enhances sedation). ✔ Do not abruptly stop medication (risk of withdrawal or rebound symptoms). Drugs Used to Treat Anxiety Barbiturates (-barbital drugs) Mechanism: Increases GABA channel opening duration, leading to CNS depression. High Risk: Can cause fatal overdose; should never be prescribed for psychiatric use. Benzodiazepines Mechanism: Increases GABA channel opening frequency, enhancing calming effects. Lower toxicity compared to barbiturates, but still risk of dependence and withdrawal. Benzodiazepines for Anxiety ✔ Immediate symptom relief → Rapid onset, noticeable anxiety reduction. ✔ High risk of tolerance & dependence → Psychological & physiological tolerance develops. ✔ Potential for abuse & addiction → Caution with long-term use. Side Effects: Sedation Memory impairment Cognitive dulling Dizziness Special Considerations: Not recommended for patients over 65 (risk of falls, confusion, cognitive decline). May worsen anxiety & depression long-term → Rebound anxiety when discontinued. Benzodiazepines Used to Treat Anxiety -azepam Drugs: ✔ Diazepam (Valium) ✔ Clonazepam (Rivotril) ✔ Lorazepam (Ativan) ✔ Flurazepam (Dalmane) ✔ Temazepam (Restoril) ✔ Nitrazepam (Mogadon) ✔ Oxazepam (Serax) -azolam Drugs: ✔ Alprazolam (Xanax) ✔ Triazolam (Halcion) 🔹 Short-term use recommended due to risk of dependence, sedation, and cognitive effects. 🔹 Fast-acting but not ideal for long-term anxiety management. Benzodiazepines Used to Treat Anxiety Short-Acting Benzodiazepines ✔ Used as hypnotics → Induce sleep. ✔ Drugs: Triazolam, Oxazepam, Midazolam ✔ Sedation wears off quickly, increasing withdrawal risk. Long-Acting Benzodiazepines ✔ Drugs: Diazepam, Chlordiazepoxide (Librium) ✔ Librium is effective for alcohol (ETOH) detox. Intermediate-Acting Benzodiazepines (Most commonly prescribed) ✔ Drugs: Lorazepam, Clonazepam, Alprazolam, Temazepam ✔ Balanced duration → Less frequent dosing than short-acting but lower risk of accumulation than long-acting. Key Points to Keep in Mind ✔ Psychotherapy is the first-line treatment for anxiety disorders. ✔ Benzodiazepines should only be used short-term due to risk of dependence, withdrawal, and long-term worsening of anxiety. Nursing Management: Psychological Domain Assessment: ✔ Suicide Assessment → Screen for self-harm risk. ✔ Panic Attack Patterns → Identify triggers, symptoms, and coping responses. ✔ Mental Status Exam (MSE): Restlessness, irritability Watchful or worried facial expression Decreased attention span Difficulty problem-solving Feelings of helplessness ✔ Cognitive Thought Patterns → Assess catastrophic thinking, irrational fears, and avoidance behaviors. ✔ Self-Concept → Evaluate self-esteem and perception of control over anxiety. Nursing Interventions: Psychological Domain When Panic Strikes: ✔ Stay with the client → Provide support and prevent escalation. ✔ Reassure them → Let them know you will not leave. ✔ Use clear, short sentences → Simple communication to reduce confusion. ✔ Move to a calm environment → Minimize stimulation to help ground them. ✔ Encourage movement → Walk with the client to reduce agitation. ✔ Administer PRN anxiolytics → If prescribed, to help relieve symptoms. ✔ Guide deep breathing exercises → Slow breathing helps interrupt hyperventilation. Clinical Picture: Other Anxiety Disorders ✔ Separation Anxiety Disorder → Excessive, developmentally inappropriate distress when away from a significant other. ✔ Agoraphobia → Intense fear or anxiety about situations where escape may be difficult or embarrassing (e.g., public transport, open spaces, crowds). ✔ Specific Phobias → Irrational fear of a particular object, situation, or activity, leading to avoidance behavior Clinical Picture: Other Anxiety Disorders (ADs) ✔ Social Anxiety Disorder → Severe fear of social or performance situations due to worry about negative evaluation by others. ✔ Substance-Induced Anxiety Disorder → Anxiety triggered by substance use or withdrawal (e.g., caffeine, alcohol, drugs). ✔ Anxiety Due to a Medical Condition → Anxiety symptoms directly caused by a medical issue (e.g., hyperthyroidism, cardiac conditions). Generalized Anxiety Disorder (GAD) ✔ Key Features: Excessive, persistent anxiety & worry for ≥6 months. Exaggerated concerns about everyday issues. Interferes with daily functioning (work, relationships, decision-making). ✔ Prevalence: Common → 10% will experience it in their lifetime. Women affected 2x more than men. ✔ Comorbidities: Frequently co-occurs with depression. Associated with substance use (self-medication for anxiety). Etiology of Generalized Anxiety Disorder (GAD) ✔ Neurochemical Theories → Limited research, but neurotransmitter dysregulation may play a role. ✔ Genetic Theories → Moderately inherited, with family history increasing risk. ✔ Psychological Theories: Inaccurate assessment of the environment → Overestimating threats. Selective focus on negative details → Cognitive distortions and pessimism. Distorted information processing → Misinterpreting neutral situations as dangerous. ✔ Social Theories: High-stress lifestyle → Chronic exposure to stress. Multiple stressful events → Life challenges contribute to anxiety development. Key Symptoms of GAD: ✔ Constant Worry → Persistent, uncontrollable thoughts about everyday concerns. ✔ Difficulty Sleeping → Insomnia or restless sleep due to excessive worry. ✔ Exaggerated Worry → Overreacting to situations with heightened anxiety. ✔ Muscle Tension → Chronic physical tension, leading to aches or stiffness. ✔ Easily Startled → Heightened sensitivity to sudden stimuli. ✔ Headaches → Frequent tension headaches due to prolonged stress. Nursing Management: Biological Domain (GAD) Assessment: ✔ Diet & Nutrition → Assess for caffeine sensitivity, which can worsen anxiety symptoms. ✔ Sleep Patterns → Evaluate sleep disturbances, as insomnia and poor sleep quality are common in GAD. Psychopharmacologic Treatment for GAD ✔ Benzodiazepines → No longer first-line due to risk of dependence. ✔ Non-Benzodiazepines → Buspirone (preferred for long-term use, lower abuse potential). ✔ Antidepressants (First-line treatment): SSRIs (e.g., Sertraline, Paroxetine) SNRIs (e.g., Duloxetine, Venlafaxine) 🔹 SSRIs & SNRIs are the mainstay due to lower risk of dependence and effectiveness in managing chronic anxiety. Nursing Management: Psychosocial Domain (GAD) Assessment: (Similar to Panic Disorder) ✔ Mental Status Exam (MSE): Anxiety is out of proportion to the situation. Restlessness, fatigue, poor concentration, irritability, muscle tension are common. Interventions: (Similar to Panic Disorder) ✔ Cognitive Psychotherapy (CBT) → Most effective treatment for GAD. ✔ Goals: Reduce frequency & intensity of anxiety. Gain control over contributing factors. Nursing Management: Psychosocial Domain (GAD) Assessment: (Similar to Panic Disorder) ✔ Mental Status Exam (MSE): Anxiety is out of proportion to the situation. Restlessness, fatigue, poor concentration, irritability, muscle tension are common. Interventions: (Similar to Panic Disorder) ✔ Cognitive Psychotherapy (CBT) → Most effective treatment for GAD. ✔ Goals: Reduce frequency & intensity of anxiety. Gain control over contributing factors. Obsessive-Compulsive Disorder (OCD) ✔ Now classified separately in the DSM-5 (no longer under anxiety disorders). ✔ Key Features: Obsessions → Recurrent, intrusive thoughts causing distress. Compulsions → Repetitive behaviors or mental acts performed to reduce anxiety. ✔ Severe impact on daily functioning, often time-consuming and distressing. Obsessive-Compulsive Disorders (OCD) ✔ Obsessions: Unwanted, intrusive thoughts, impulses, or images that persist and recur. Cannot be dismissed, causing significant anxiety and distress. ✔ Compulsions: Repetitive, ritualistic behaviors performed to reduce anxiety. Interruption of compulsions → Leads to increased anxiety. Types of Obsessive-Compulsive Disorders (OCD-Related Disorders) ✔ Obsessive-Compulsive Disorder (OCD) → Recurrent obsessions and compulsions that disrupt daily life. ✔ Body Dysmorphic Disorder (BDD) → Preoccupation with perceived physical flaws, leading to repetitive behaviors (e.g., mirror checking, excessive grooming). ✔ Hoarding Disorder → Persistent difficulty discarding possessions, leading to clutter and distress. ✔ Hair-Pulling Disorder (Trichotillomania) → Compulsive pulling of hair, causing hair loss. ✔ Skin-Picking Disorder (Excoriation Disorder) → Repetitive picking of skin, leading to tissue damage. ✔ Other Compulsive Disorders → Includes compulsive shopping, gaming, or internet use impacting daily functioning Epidemiology of OCD ✔ Occurs on a continuum, ranging from mild to severe. ✔ 4th most common psychiatric illness. ✔ Lifetime prevalence: 2.5% in adults. ✔ Age of Onset: Bimodal distribution: Peaks at 10 years & 21 years. Childhood OCD: Diagnosed 3x more in boys than girls. In adults, prevalence is equal in men and women. Males tend to have an earlier onset than females. ✔ Genetic Link: Higher prevalence if first-degree relatives have OCD. Comorbidity of OCD ✔ Frequently co-occurs with: Mood Disorders → Rumination (e.g., depression). Anxiety Disorders → Excessive worry and distress. ✔ Psychotic Disorders May Co-Occur, but: People with OCD alone typically recognize their thoughts as irrational. Despite recognition, they struggle to control their obsessions and compulsions. Etiology of OCD ✔ Genetic Factors → Higher prevalence in first-degree relatives. ✔ Neurobiological Factors → Abnormalities in: Frontal Cortex (decision-making, impulse control). Limbic System (emotional regulation). Basal Ganglia (motor control, habit formation). ✔ Behavioral Theories: Learned behaviour → Rituals reduce anxiety, reinforcing compulsions (primary gain). ✔ Obsessions → Create intense anxiety. ✔ Compulsions → Performed to reduce anxiety. Most Common Obsession: ✔ Fear of contamination (e.g., germs, dirt). Common Compulsions: ✔ Washing, cleaning, checking, counting. ✔ Repeating actions, ordering, confessing, seeking reassurance. ✔ Disruption of ritual sequence → Triggers high anxiety and distress. Nursing Management: Biologic Domain (OCD) Assessment: ✔ Multiple Physical Symptoms → Assess for somatic complaints related to anxiety. ✔ Physical Fears → Identify specific fears (e.g., contamination, harm). ✔ Physical Consequences of Compulsions → Evaluate for injuries or exhaustion due to repetitive behaviors. ✔ Nutrition & Sleep Status → Check for weight loss, malnutrition, or sleep disturbances caused by compulsive rituals. ✔ Dermatologic Lesions → Monitor for skin damage due to excessive handwashing or cleaning behaviors. Psychopharmacologic Treatment for OCD ✔ Antidepressants (First-Line Treatment): SSRIs: Fluvoxamine, Fluoxetine, Paroxetine, Sertraline TCA: Clomipramine (Gold standard for OCD) Teaching Points: ✔ Do not stop medication abruptly → Risk of withdrawal symptoms. ✔ Avoid OTC medications → Possible interactions. ✔ Consider sedative effects → May cause drowsiness, affecting daily activities. Nursing Management: Psychological Domain (OCD) Assessment: ✔ Suicide Risk Assessment → Monitor for self-harm thoughts due to distress. ✔ Type & Severity of Obsessions & Compulsions → Identify specific patterns and triggers. ✔ Impact on Daily Functioning → Assess degree of interference with work, relationships, and self-care. ✔ Use Rating Scales → Standardized tools (e.g., Yale-Brown Obsessive Compulsive Scale [Y- BOCS]) to measure symptom severity. Nursing Interventions: Psychological Domain (OCD) Priority Care Issues: ✔ Monitor for suicide risk → Intrusive thoughts can increase distress and self-harm risk. ✔ Be non-judgmental & supportive → Foster trust and a therapeutic relationship. ✔ Set realistic expectations → Understand that behaviors are rigid and difficult to change. ✔ Encourage gradual exposure & response prevention → Support CBT-based interventions to reduce compulsions. Nursing Interventions: Psychological Domain (OCD) Priority Care Issues: ✔ Clearly explain unit routines → Reduces fear of the unknown and helps the client feel in control. ✔ Assist in arranging a structured schedule → Helps manage compulsions while promoting daily activities. Outpatient Interventions: ✔ Cognitive Restructuring → Challenging irrational thoughts. ✔ Thought Stopping → Interrupting obsessive thinking patterns. ✔ Exposure Therapy → Gradual exposure to triggers with response prevention. ✔ Psychoeducation → Teaching coping strategies and understanding OCD. Nursing Process & Anxiety Disorders Assessment: ✔ General Symptom Evaluation → Assess across cognitive, affective, physiological, and behavioral domains. ✔ Use the Hamilton Rating Scale for Anxiety (HAM-A) → Measures severity (Table 12-9). ✔ Self-Assessment → Recognize personal biases or emotional responses when caring for anxious clients. ✔ Follow Anxiety Disorder Assessment Guidelines (p. 219) → Structured framework for evaluation. Common Nursing Diagnoses: ✔ Anxiety → Related to excessive worry, fear, or stressors. ✔ Ineffective Coping → Inability to manage stress or triggers effectively. ✔ Disturbed Sleep Pattern → Due to persistent worry or panic symptoms. ✔ Risk for Self-Harm → If intrusive thoughts or distress become overwhelming. ✔ Impaired Social Interaction → Due to avoidance behaviors. Application of the Nursing Process: Anxiety Disorders Outcomes Identification (Table 12-14) ✔ Goals should focus on: Reducing anxiety symptoms to a manageable level. Improving coping strategies for daily functioning. Enhancing problem-solving abilities in response to stressors. Planning: ✔ Hospital or Community-Based Care: Ensure a safe, supportive environment. Provide structured routines to reduce uncertainty. ✔ Client Involvement: Engage clients with mild to moderate anxiety in collaborative care planning. Encourage active participation in goal-setting, treatment decisions, and coping strategies. Goals of Treatment for Anxiety Disorders ✔ The client will use effective coping strategies → Develop and apply healthy techniques to manage anxiety. ✔ The client will report a decreased intensity of anxiety → Verbalize improvement in symptoms and distress levels. ✔ The client will use breathing techniques to control anxiety & hyperventilation → Implement deep breathing exercises to regulate physiological responses. Implementation: Alleviating Anxiety ✔ Initiate a Therapeutic Dialogue → Encourage open expression of fears and concerns. ✔ Counter Faulty Thinking → Challenge cognitive distortions and promote realistic thinking. ✔ Manage Hyperventilation → Teach controlled breathing techniques (e.g., diaphragmatic breathing). ✔ Suggest Lifestyle Changes → Promote exercise, balanced diet, sleep hygiene, and caffeine reduction. Teaching Adaptive Coping Strategies: ✔ Relaxation Techniques → Progressive muscle relaxation, guided imagery. ✔ Visualization → Encourage positive mental imagery to reduce stress. ✔ Problem-Solving Strategies → Help clients identify stressors and develop effective solutions. Implementation (Continued): Managing Anxiety For Mild to Moderate Anxiety (Table 12-15) ✔ Encourage problem-solving & cognitive reframing. ✔ Use active listening & therapeutic communication. ✔ Teach relaxation techniques & stress management strategies. For Severe to Panic Levels of Anxiety (Table 12-16) ✔ Ensure safety → Stay with the client, use a calm, reassuring presence. ✔ Reduce environmental stimuli → Move to a quiet area if needed. ✔ Use short, simple statements → Assist in grounding. ✔ Administer PRN medication if prescribed. Other Key Interventions: ✔ Pharmacological Interventions: Antidepressants → SSRIs, SNRIs (first-line treatment). Anxiolytics → Benzodiazepines (short-term use). ✔ Psychobiological Interventions: Encourage mind-body techniques (e.g., mindfulness, biofeedback). ✔ Health Teaching & Counseling: Educate on coping strategies, lifestyle modifications, & medication adherence. Address misconceptions about anxiety & treatment. ✔ Teamwork & Safety: Collaborate with interdisciplinary team members (psychiatrists, therapists, case managers). ✔ Promotion of Self-Care Activities: Encourage good nutrition, sleep, & physical activity. ✔ Community Resources & Referrals: Connect clients with support groups, counseling services, & crisis intervention programs. Advanced-Practice Interventions for Anxiety Disorders ✔ Cognitive Therapy → Helps clients identify and challenge distorted thinking that contributes to anxiety. ✔ Behavioral Therapy Techniques: Relaxation Training → Teaches progressive muscle relaxation & deep breathing. Modeling → Client observes appropriate coping behaviors in others. Systematic Desensitization → Gradual exposure to anxiety-provoking stimuli while using relaxation techniques. Flooding → Intense, prolonged exposure to the feared stimulus to reduce anxiety quickly. Response Prevention → Prevents compulsions/avoidance behaviors, forcing the client to confront anxiety. Thought Stopping → Interrupts negative thoughts using a verbal or physical cue (e.g., snapping a rubber band). ✔ Cognitive-Behavioral Therapy (CBT) → Gold standard for anxiety treatment Combines cognitive restructuring with behavioral techniques to help clients change thought patterns and behaviors. Community Resources for Anxiety Support (Winnipeg, MB) Self-Help & Support Groups: Anxiety Disorders Association of Manitoba (ADAM) – CBT-based support programs Winnipeg OCD Support Group – Peer-led OCD support Mood Disorders Association of Manitoba – Peer support for anxiety & depression Counseling Services: Klinic Community Health – Trauma-informed therapy Aurora Family Therapy Centre – Family & individual therapy Thrive Counselling – Inclusive mental health services U of M Psychological Service Centre – Low-cost therapy, assessments Additional Resources: Anxiety Canada – Free self-help tools & programs Anxiety Disorders Clinic (St. Boniface Hospital) – Specialized treatment for severe anxiety Key Terms: Somatic Symptom Disorders ✔ Psychosomatic → Psychological factors contribute to physical illness (e.g., "Broken Heart Syndrome" – stress-induced cardiomyopathy). ✔ Somatization → Unexplained physical symptoms resulting from psychological distress. Highlights the mind-body connection and the influence of anxiety on physical health. Clinical Picture of Somatic Symptom Disorders ✔ Somatic Symptom Disorder (SSD) → Excessive focus on physical symptoms (e.g., pain, fatigue) that cause significant distress despite no clear medical explanation. ✔ Illness Anxiety Disorder (Hypochondriasis) → Preoccupation with having a serious illness, despite minimal or no symptoms and normal medical evaluations. ✔ Conversion Disorder → Neurological symptoms (e.g., paralysis, blindness, seizures) that have no medical cause but are linked to psychological stress. ✔ Psychological Factors Affecting Medical Condition → Mental health issues worsen or contribute to a medical illness (e.g., stress-induced high blood pressure). ✔ Factitious Disorder → Intentional falsification or induction of illness for emotional or psychological gain (without external incentives like financial gain). Somatic Symptom & Related Disorders ✔ Somatization → Psychological stress manifests as physical symptoms. ✔ Prevalence → Affects women, men, & children, making up ~25% of primary care visits. ✔ Contributing Factors → Anxiety, depression, & trauma play a significant role in these complex psychological-physical experiences. Epidemiology of Somatic Symptom Disorders ✔ Prevalence rates are unknown due to variability in presentation. ✔ Common in medical settings → Seen in individuals seeking medical care without an identifiable physiological cause for their symptoms. Comorbidity of Somatic Symptom Disorders ✔ Comprehensive psychosocial history is essential to confirm diagnosis and identify comorbidities. ✔ Common comorbid disorders: Depressive disorders Psychotic disorders Anxiety disorders ✔ Psychological factors can increase risk for medical diseases or worsen existing conditions (e.g., stress exacerbating hypertension or chronic pain). Somatic Symptom Disorder (SSD) ✔ Distressing symptoms → Persistent physical complaints causing significant discomfort. ✔ Maladaptive response → Excessive thoughts, feelings, or behaviors related to symptoms. ✔ No significant medical explanation → Symptoms exist without clear physical findings or diagnosis. ✔ Suffering is real → The distress is authentic, even if no medical cause is found. ✔ High functional impairment → Symptoms interfere with daily life, work, and relationships. Clinical Course of Somatic Symptom Disorder (SSD) ✔ Diagnosis typically after age 30. ✔ 10x more common in women than men. ✔ Frequent doctor visits → Multiple medical consultations and treatments, often with little to no relief. Clinical Course of Somatic Symptom Disorder (SSD) ✔ Most Common Symptoms: Chest pain, fatigue, dizziness, headache, swelling, back pain Shortness of breath (SOB), insomnia, abdominal pain, numbness ✔ Prevalence in Healthcare: 40% of all healthcare visits involve these symptoms. Only 26% of cases have a clear biological cause. ✔ Associated Psychological Symptoms: High rates of anxiety & depression. Patients often feel devalued & stigmatized in medical settings. Etiology of Somatic Symptom Disorder (SSD) ✔ Biological Factors → Possible genetic predisposition. ✔ Psychological Factors: Psychodynamic Theories → Symptoms may be unconscious expressions of internal conflict. Behavioral Theories → Symptoms reinforced through attention, care, or avoidance of responsibilities. Cognitive Theories → Misinterpretation of normal bodily sensations as signs of serious illness. ✔ Environmental Factors → Early trauma, stress, or learned illness behaviors from caregivers. ✔ Cultural Considerations → Somatic symptoms may be culturally influenced expressions of distress. Interdisciplinary Treatment for Somatic Symptom Disorder (SSD) ✔ Long-Term Management → Focus on chronic care rather than symptom elimination. ✔ Comorbid Treatment → Address both psychiatric (e.g., anxiety, depression) and physical conditions. ✔ Specialized Care Settings → Support groups, psychoeducation, and structured therapy. ✔ Key Consideration: Symptoms are NOT under voluntary control → Avoid judgment and emphasize supportive care. Assessment of the Biological Domain (Somatic Symptom Disorder - SSD) ✔ Review of Systems → Identify physical complaints and patterns of symptoms. ✔ Pain Assessment → Evaluate location, intensity, duration, and impact on daily life. ✔ Physical Functioning → Assess mobility, daily activities, and any physical limitations. ✔ Pharmacological Assessment: Polypharmacy → Client may be taking multiple medications for symptom relief. Substance Use → Possible self-medication with drugs or alcohol to manage distress. Assessment of the Psychological Domain (Somatic Symptom Disorder - SSD) ✔ Mental Status → Usually normal, no cognitive impairment. ✔ Preoccupation with Illness → Constant focus on symptoms, may carry detailed medical records. ✔ Emotional Reactions to Stress → Assess coping mechanisms and response to life stressors. ✔ Discordant Mood (La Belle Indifférence) → Flat affect despite severe symptoms, showing little emotional response to distressing conditions. ✔ Alexithymia → Difficulty recognizing or verbalizing emotions, leading to physical symptom expression instead. Assessment of the Social Domain (Somatic Symptom Disorder - SSD) ✔ Time Spent on Medical Care → Assess frequency of doctor visits, medical tests, and treatments. ✔ Extent of Disability → Evaluate impact on daily activities and quality of life. ✔ Employment Status → Determine work attendance, productivity, or disability leave. ✔ Social Network → Assess support system and relationships. ✔ Family Dynamics → Identify disruptions in family life, caregiver burden, and potential reinforcement of illness behaviors. Application of the Nursing Process (Continued) Assessment (Continued): ✔ Ability to Communicate Feelings & Emotional Needs → Assess for alexithymia (difficulty expressing emotions)and reliance on physical symptoms to express distress. ✔ Dependence on Medication → Evaluate overuse, polypharmacy, and self-medication with substances. ✔ Self-Assessment (Nurse’s Perspective) → Recognize personal biases and maintain a nonjudgmental approach to care. Application of the Nursing Process (Continued) ✔ Nursing Priority → Establish trust, validate distress, and focus on functional improvement rather than symptom elimination. ✔ Outcomes Identification: The client will develop effective coping strategies. The client will reduce excessive health-related behaviors. The client will engage in daily activities despite symptoms. ✔ Interventions: Psychosocial Support → Encourage emotional expression instead of somatic complaints. Promotion of Self-Care Activities → Help client increase independence and engage in meaningful activities. Assertiveness Training → Teach healthy communication skills to reduce passive or avoidant behaviors related to stress. Biological Nursing Interventions for Somatic Symptom Disorder (SSD) ✔ Acknowledge Physical Complaints → Spend time validating symptoms without reinforcing illness behaviors. ✔ Establish a Daily Routine → Promote structured activities to reduce focus on symptoms. ✔ Monitor Medication Use → Assess for polypharmacy and dependence on medications. ✔ Pain Management → Use multiple approaches (e.g., non-pharmacological methods like relaxation, physical therapy, CBT). ✔ Encourage Physical Activity → Increase movement and engagement in enjoyable activities. ✔ Nutrition Regulation → Promote balanced eating habits to improve overall health. ✔ Relaxation Techniques → Teach deep breathing, meditation, and mindfulness to reduce stress. Pharmacological Interventions for Somatic Symptom Disorder (SSD) ✔ No specific medication for SSD → Treatment focuses on comorbid conditions. ✔ Medications for Comorbid Disorders: Depression → SSRIs (e.g., Sertraline, Fluoxetine), MAOIs (rarely used, require dietary restrictions). Anxiety → Avoid benzodiazepines due to risk of dependence; use SSRIs or SNRIs instead. ✔ Nursing Considerations: Monitor closely for effectiveness and side effects. Watch for drug-drug interactions, especially with polypharmacy. Educate patients on medication adherence and potential side effects. Psychological Interventions for Somatic Symptom Disorder (SSD) ✔ Establish a Trusting Relationship → Gold standard for effective care, helping reduce distress and resistance to treatment. ✔ Manage Ineffective Coping → Encourage adaptive coping strategies instead of excessive health-seeking behaviors. ✔ Assess Health-Seeking Behaviors → Identify patterns and triggers for symptom exacerbation. ✔ Address Powerlessness & Dependency → Foster autonomy, confidence, and problem-solving skills. ✔ Enhance Self-Esteem → Support positive self-image and emotional resilience. ✔ Promote Social & Family Engagement → Encourage re-engagement in social activities and family interactions to improve quality of life. Trauma & Stressor-Related Disorders ✔ Acute Stress Disorder (ASD) → Short-term reaction to trauma (3 days to 1 month), with symptoms like flashbacks, nightmares, and hypervigilance. ✔ Post-Traumatic Stress Disorder (PTSD) → Long-term distress after trauma (lasting >1 month), including intrusive memories, avoidance, hyperarousal, and emotional numbing. ✔ Dissociative Disorders → Disruptions in memory, identity, or perception as a defense mechanism against trauma. Includes: Dissociative Amnesia → Memory loss of traumatic events. Dissociative Identity Disorder (DID) → Presence of two or more distinct personality states. Depersonalization/Derealization Disorder → Feeling detached from self (depersonalization) or surroundings (derealization). Acute Stress Disorder (ASD) ✔ Onset & Duration: Occurs within 1 month of a highly traumatic event and resolves within 4 weeks. ✔ Diagnostic Criteria: Must have at least 3 dissociative symptoms, including: Numbing, detachment, or absence of emotional response. Reduced awareness of surroundings ("zoning out"). Derealization → Feeling that the environment is unreal or distorted. Depersonalization → Feeling detached from oneself or experiencing self-estrangement. Dissociative Amnesia → Inability to recall key aspects of the traumatic event. Post-Traumatic Stress Disorder (PTSD) ✔ Definition: A chronic emotional response triggered by direct, indirect, or witnessed exposure to extreme stress or trauma. ✔ DSM-5 Classification: Now categorized under Trauma & Stressor-Related Disorders (separate from Anxiety Disorders). ✔ Progression: PTSD can develop when Acute Stress Disorder (ASD) is not resolved, leading to persistent symptomsbeyond 1 month. Major Features of PTSD ✔ Persistent Symptoms Include: Re-experiencing the Trauma → Intrusive thoughts, nightmares, flashbacks. Avoidance → Avoiding people, places, or situations that trigger trauma memories. Emotional Numbing → Detachment, lack of interest, or feeling disconnected from others. Increased Arousal Symptoms:  Irritability & anger outbursts Difficulty sleeping & concentrating Hypervigilance (constantly on edge) Exaggerated startle response (overreacting to sudden noises or movements). Risk Factors for PTSD ✔ High-Risk Groups: Survivors of severe trauma (e.g., war, assault, accidents). Genocide survivors (e.g., refugees, displaced individuals). First responders → Police, firefighters, paramedics, emergency personnel. Disaster survivors → Individuals exposed to mass trauma events (e.g., Boston Marathon bombing). ✔ Reciprocal Stress: PTSD in one family member can lead to increased stress in the entire family, affecting relationships and mental health. Clinical Picture of PTSD ✔ Trigger: Can develop after any traumatic event beyond normal experiences. ✔ Onset: Can occur within 3 months of the trauma. May also have a delayed onset, emerging years later. ✔ Core Feature: Persistent re-experiencing of a traumatic event involving threatened or actual death/injury. ✔ Emotional Response: Intense fear Helplessness Horror Three Key Symptom Dimensions of PTSD ✔ Symptom 1: Re-experiencing Intrusive images, thoughts, or perceptions related to the trauma. Recurrent distressing dreams about the event. Illusions or hallucinations (in severe cases). Flashbacks → Feeling as if the trauma is happening again. Intense emotional or physical distress when exposed to trauma-related cues. PTSD Symptoms (Continued) ✔ Symptom #2: Avoidance Avoidance of triggers → Thoughts, feelings, conversations, places, people, or activities linked to the trauma. Dissociation → Inability to recall key aspects of the trauma (psychological defense mechanism). Depersonalization → Feeling detached from oneself, as if observing from the outside. Emotional Numbing → Restricted affect, reduced emotional response, feeling empty or disconnected. PTSD Symptoms (Continued) ✔ Symptom #3: Hyperarousal Stress system remains on high alert → Constant feeling of danger. Dopamine hyperactivity → Heightened stress response. Sleep disturbances → Difficulty falling or staying asleep due to hypervigilance. Irritability & anger outbursts → Easily frustrated or short-tempered. Difficulty concentrating → Mind preoccupied with perceived threats. Hypervigilance → Always on guard, scanning for danger. Exaggerated startle response → Overreacting to sudden noises or movements. Clinical Picture of PTSD (Continued) ✔ Key Areas of Concern: Risk for suicide & homicide → Due to overwhelming distress and hopelessness. Child & spousal abuse → Increased risk of domestic violence due to emotional dysregulation & hyperarousal. Substance abuse → Self-medication with alcohol, drugs, or prescription medications to numb symptoms. Impaired relationships & functioning → Struggles with interpersonal, social, and occupational responsibilities due to avoidance, emotional detachment, or hyperarousal. Treatment Goals & Resources for PTSD ✔ Anxiety Management → Teach coping skills, relaxation techniques, and grounding exercises. ✔ Education → Help clients understand PTSD symptoms and triggers, reducing self-blame. ✔ Individual Psychotherapy → Trauma-focused cognitive behavioral therapy (TF-CBT), EMDR (Eye Movement Desensitization and Reprocessing). ✔ Psychopharmacology: Prazosin (anti-hypertensive) → Reduces PTSD-related nightmares. Monitor for orthostatic hypotension (risk of dizziness, falls). ✔ Group Therapy → Peer support, shared experiences, and coping strategies. ✔ Family Therapy → Helps rebuild relationships, communication, and understanding of PTSD impact. Dissociative Disorders ✔ Triggered by trauma or significant adverse experiences. ✔ Severe disruption of consciousness in response to extreme stress. ✔ Unconscious defense mechanism → Mind disconnects from reality to cope. ✔ Emotional separation serves as protection against overwhelming anxiety or distress. Types of Dissociative Disorders ✔ Depersonalization/Derealization Disorder → Depersonalization → Feeling detached from oneself (as if watching from outside the body). Derealization → Feeling like the environment is unreal or distorted. ✔ Dissociative Amnesia → Inability to recall personal information or traumatic events, not due to medical conditions. ✔ Dissociative Fugue → Sudden, unexpected travel away from home with amnesia about identity or past. ✔ Dissociative Identity Disorder (DID) → Two or more distinct personality states with gaps in memory. What is Dissociation? ✔ Dissociation symptoms can disrupt all areas of psychological functioning. ✔ Dissociative Disorders (DDs) involve disruptions in the integration of: Consciousness → Awareness of self and surroundings. Memory → Gaps in recall of events, personal history, or identity. Identity → Sense of self may feel fragmented or altered. Emotion → Numbness or detachment from feelings. Perception → Distorted sense of reality. Body Representation → Feeling disconnected from one's own body. Motor Control → Unexplained physical movements or paralysis. Behavior → Sudden shifts in personality, actions, or emotional responses. What is Dissociation? (Continued) ✔ Dissociative symptoms are experienced in two ways: 1 Positive Dissociative Symptoms → Intrusions into awareness and behavior, causing a disrupted sense of self: Fragmentation of identity → Feeling like multiple versions of oneself. Depersonalization → Feeling detached from one’s body or thoughts. Derealization → Experiencing the world as unreal or distorted. 2 Negative Dissociative Symptoms → Inability to access or control normal mental functions: Amnesia → Gaps in memory, often involving traumatic events. Loss of control over mental processes → Difficulty accessing emotions, thoughts, or personal history. Dissociative Disorders (Continued) ✔ Epidemiology: (Prevalence debated, some sources suggest underreporting) Depersonalization Disorder: 1-3% of the population. Dissociative Amnesia: 2-7% of the population. Highly comorbid with Anxiety & Depression → Often co-occurs with trauma-related disorders. ✔ Etiology: Bio-Psycho-Social Factors → Genetic vulnerability, trauma, and environmental influences. Diathesis-Stress Model → Predisposition (diathesis) + severe stressor/trauma = disorder development. Etiology of Dissociative Disorders ✔ Biological Factors: Genetics → Possible hereditary vulnerability. Trauma-Induced Brain Changes → Altered brain function in areas related to memory and emotion (e.g., hippocampus, amygdala). ✔ Psychological Factors: Learned Stress-Avoidance → Dissociation becomes a coping mechanism to escape distress. ✔ Environmental Factors: Exposure to Trauma → Childhood abuse, neglect, war, or severe emotional distress. ✔ Cultural Considerations: Rule out culture-bound disorders → Some dissociative symptoms may be culturally accepted or interpreted differently in various societies. Depersonalization/Derealization Disorder ✔ Depersonalization → Focus on self Feeling detached from one's own body, thoughts, or emotions. Experiencing oneself as unreal or robotic (e.g., “I feel like I’m watching myself from outside”). ✔ Derealization → Focus on the outside world Feeling like the environment or surroundings are unreal, dreamlike, or distorted. Objects may appear blurry, altered in size, or distant (e.g., “The world feels fake, like a movie”). Depersonalization Disorder ✔ Key Features: Persistent or recurrent detachment from self. Feeling like an outside observer of one’s thoughts, emotions, or body (e.g., “I feel like I’m in a dream”). ✔ Reality Testing Remains Intact: The person knows the experience is not real, distinguishing it from psychosis. ✔ Impact on Functioning: Causes significant distress or impairment in daily life. ✔ Not Due to: Substance use (e.g., drug-induced states). Medical conditions (e.g., neurological disorders). Derealization Disorder ✔ Key Features: Persistent or recurrent sense of unreality about surroundings. The world feels dreamlike, distant, foggy, or distorted. ✔ Examples: Objects may appear blurry, unusually large/small, or artificial. Sounds may feel muted or distant. ✔ Impact on Functioning: Causes clinically significant distress or impairment in daily life. ✔ Not Due to: Substance use (e.g., drug-induced hallucinations). Medical conditions (e.g., neurological disorders). Reality testing remains intact (person knows their perception is altered). Dissociative Amnesia (“loss of memory”) ✔ Previously Known As: Psychogenic Amnesia. ✔ Key Feature: Inability to recall important personal information, typically related to trauma or extreme stress. ✔ Beyond Normal Forgetting: Memory loss is too extensive to be explained by typical forgetfulness. ✔ Not Due To: Substance use (e.g., alcohol, drugs). Medical conditions (e.g., brain injury, dementia). ✔ Impact on Functioning: Causes significant distress or impairment in social, occupational, or daily life activities. Dissociative Fugue ("Loss of Time") ✔ Previously Known As: Psychogenic Fugue. ✔ Key Features: Sudden, unexpected travel away from home or usual surroundings. Inability to recall personal identity or past. May experience confusion about identity or even assume a new identity (complete or partial). ✔ Memory Recovery: Once the former identity is remembered, the person forgets the time spent in the fugue state. ✔ Impact on Functioning: Causes distress or impairment in daily life. Not due to substance use or a medical condition. Dissociative Identity Disorder (DID) ✔ Key Feature: Presence of two or more distinct personality states. ✔ Disruption of Identity Includes: Discontinuity in sense of self and personal agency (control over actions). Changes in: Affect (emotions) Behavior Consciousness & memory Perception & cognition Sensory-motor functioning ✔ Symptoms May Be: Observed by others (e.g., personality shifts, different voices or mannerisms). Reported by the patient (e.g., unexplained gaps in memory, feeling like a different person). Dissociative Identity Disorder (DID) – Continued ✔ Memory Gaps: Recurrent gaps in recall of everyday events, personal information, or trauma. Memory loss is too extensive to be explained by ordinary forgetting. ✔ Impact on Functioning: Causes significant distress or impairment in social, occupational, or other important areas. ✔ Not Explained By: Cultural or religious practices (e.g., spirit possession within cultural beliefs). Substance use or medical conditions (e.g., epilepsy, head injury). Dissociative Identity Disorder (DID) – Continued ✔ Memory Gaps: Recurrent gaps in recall of everyday events, personal information, or trauma. Memory loss is too extensive to be explained by ordinary forgetting. ✔ Impact on Functioning: Causes significant distress or impairment in social, occupational, or other important areas. ✔ Not Explained By: Cultural or religious practices (e.g., spirit possession within cultural beliefs). Substance use or medical conditions (e.g., epilepsy, head injury). Dissociative Identity Disorder (DID) – Continued ✔ Primary Personality (Host): Usually unaware of the existence of alters. ✔ Alternate Personalities (Alters): Each alter has a distinct way of: Perceiving → Views the world differently. Relating to others → Different social behaviors or mannerisms. Thinking about self & environment → Unique memories, preferences, and emotions. Dissociative Disorders - Nursing Assessment ✔ Suicide Risk → Assess for self-harm or suicidal ideation, especially in DID and dissociative amnesia. ✔ History → Explore trauma history, onset, and pattern of dissociative episodes. ✔ Moods → Evaluate for depression, anxiety, emotional numbness, or mood shifts. ✔ Impact on Patient & Family → Assess relationship difficulties, functional impairment, and distress in loved ones. ✔ Self-Assessment (Nurse's Perspective) → Be aware of biases, remain nonjudgmental, and validate the patient’s experiences. Dissociative Disorders - Implementation ✔ Interventions: Ensure safety → Monitor for self-harm or suicidal ideation. Grounding techniques → Help patients stay present (e.g., touch objects, deep breathing). Build trust → Provide consistent, nonjudgmental care. ✔ Psychoeducation: Teach about dissociation as a coping mechanism. Educate patients and families on triggers, symptom management, and self-care. ✔ Pharmacological Interventions: (No specific medication for dissociative disorders, but used for comorbid conditions) Antidepressants (SSRIs, SNRIs) → Manage depression and anxiety. Mood stabilizers or antipsychotics → Help with mood swings or intrusive symptoms. ✔ Advanced-Practice Interventions: Trauma-focused psychotherapy (e.g., CBT, EMDR). Hypnotherapy → May help access and process traumatic memories. ✔ Somatic Therapy: Focuses on body-based approaches (e.g., yoga, movement therapy) to reconnect mind and body. ✔ Evaluation: Assess for improvements in symptom management, emotional regulation, and daily functioning.