Anxiety Disorders Sept 2023 Student Notes PDF

10/4/2023 Anxiety & Related Disorders Obsessive-Compulsive Disorders Trauma & Stressor-Related Disorders: Acute Stress Disorder Post-traumatic Stress Disorder Dissociative Disorders 1 Concept of Anxiety ❖ Anxiety: An uncomfortable feeling of apprehension, dread, uneasiness, & uncertainty ❖ ❖ ❖...

10/4/2023 Anxiety & Related Disorders Obsessive-Compulsive Disorders Trauma & Stressor-Related Disorders: Acute Stress Disorder Post-traumatic Stress Disorder Dissociative Disorders 1 Concept of Anxiety ❖ Anxiety: An uncomfortable feeling of apprehension, dread, uneasiness, & uncertainty ❖ ❖ ❖ ❖ ❖ ❖ ❖ These feelings may come from either a real or perceived threat Response to internal or external stimuli Anxiety is the subjective response to stress Physical, emotional, cognitive, & behavioural Sx Fear: Reaction to specific danger The body reacts to anxiety & fear in the same way: E.g. “Fight or flight response” “Normal” anxiety is necessary for survival 2 “Normal” vs. Abnormal ➢ ➢ ➢ ➢ “Normal” anxiety: Motivates us to make & survive change Acute anxiety: Triggered by an external event or stimuli, e.g., before surgery Chronic anxiety: Unresolved anxiety over time, prolonged use of maladaptive defensive coping mechanisms (which were adaptive short-term) Panic: Extreme overwhelming form of anxiety, lifethreatening (or perceived) situation ➢ “Normal” becomes abnormal when panic is experienced routinely, or in situations that do not pose threats 3 1 10/4/2023 Normal vs. Abnormal Anxiety ➢ Anxiety may become pathological when: ➢ ➢ ➢ ➢ ➢ ➢ No real threat exists It is of greater than expected intensity It prevents fulfillment of roles It is accompanied by flashbacks, obsessions, or compulsions It inhibits daily/social functioning It lasts longer than expected 4 Levels of Anxiety: A continuum (Table 12-1) Mild anxiety ◼ Moderate anxiety ◼ Severe anxiety ◼ Panic ◼ 5 Mild Anxiety ❖ Assessment: ❖ Nursing Interventions: 6 2 10/4/2023 Mild Anxiety ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ Assessment: Alert No thought distortions Still open to problem solving Slight discomfort restlessness irritability tension-relieving behaviors 7 Mild Anxiety ❖ ➢ ➢ ➢ ➢ Nursing Interventions: Stay calm, engage in conversation; Use open-ended questions, Active listening Check past coping behaviors, what worked; Explore alternatives (See Table 12-15) 8 Moderate Anxiety ❖ Assessment: ❖ Nursing Intervention: 9 3 10/4/2023 Moderate Anxiety ❖ ❖ ❖ ❖ ❖ ❖ Assessment: Anxiety increases Selective Inattention Can problem-solve with assistance as thinking becomes less clear Increased physical tension more extreme tension-reliving behaviors 10 Moderate Anxiety ❖ ❖ ❖ ❖ ❖ ❖ Nursing Intervention: Goal is to intervene at this level before it increases! Offer more 1:1 attention coach on deep breathing techniques use simple communication work together through problem-solving Also encourage physical activity; Distraction is also helpful 11 Severe Anxiety ❖ Assessment: ❖ Nursing Intervention: 12 4 10/4/2023 Severe Anxiety ❖ Assessment: Distorted perceptions Unable to focus ❖ Learning & problem-solving is not possible ❖ Increase in somatic complaints ❖ May see hyperventilation ❖ ❖ 13 Severe Anxiety ❖ ❖ ❖ ❖ ❖ Nursing Intervention: Goal is to reduce anxiety to moderate level Because of the client’s “tunnel vision” at this point, increase level of observation, destimulate the environment, focus on here & now, Provide anxiolytic role play deep breathing, focus on what the client can do (see table 12-16) 14 Panic ❖ Assessment: ❖ Nursing Interventions: 15 5 10/4/2023 Panic ❖ ❖ ❖ ❖ ❖ ❖ Assessment: Most extreme level of anxiety with disturbed behavior & perceptions Loss of touch with reality Possible hallucinations ++Psychomotor agitation Poor reasoning & inattention May become mute 16 Panic Nursing Interventions: ◼ Don’t touch the client but let your presence be known ◼ Stay calm ◼ Use clear & simple statements ◼ Reinforce reality ◼ NB: Maintain physical safety of clients ◼ Provide PRN meds & assess 17 Defenses Against Anxiety ◼ Defense mechanisms ◼ ◼ ◼ Automatic coping styles Protect people from anxiety Maintain self-image by blocking: ◼ ◼ ◼ ◼ ◼ Feelings Conflicts Memories Can be healthy or unhealthy (Table 12-2) Goal: Support the use of appropriate defense mechanisms, that can assist in reducing anxiety 18 6 10/4/2023 Cognitive Distortions Can be linked in theory to causes of symptoms of anxiety ❖ Some Examples: ◼ ◼ ◼ ◼ ◼ Emotional reasoning - Anxiety disorders Catastrophizing - Social anxiety, social phobia, panic disorders Control fallacies - OCD Perfectionism- Anxiety disorders Should/Must statements - OCD 19 20 Epidemiology & Comorbidity: Anxiety Disorders ◼ ◼ ◼ ◼ 11.6% of Canadians over age 18 Increasing prevalence in children & youth with the highest increase in prevalance for those aged 5-10 years Higher percentage seen in women, separated/divorced, & survivors of abuse Co-occurring with depressive disorders in 60% of cases ◼ Treatments for both disorders are similar due to shared neurobiology, symptom similarities, & abnormalities of emotional processing 21 7 10/4/2023 Clinical Picture: Anxiety Disorders ◼ ◼ ◼ ◼ Common characteristic in all anxiety disorders is emotional distress Clients feel that the core of their personality is being threatened, even when there is no danger Common manifestations of symptoms involve: Rigid, repetitive, & ineffective behaviours to try to control the anxiety Those more likely to seek treatment: Panic Disorder & Generalized Anxiety Disorder (GAD) 22 Clinical Picture: Anxiety Disorders ◼ ◼ Excessive fear resulting in altered perceptions & behaviour Anxiety is a factor in a number of disorders, including: ◼ Acute stress disorder ◼ Anxiety disorder not otherwise specified ◼ Anxiety due to medical conditions ◼ Depersonalization/derealization disorder ◼ Generalized anxiety disorder ◼ Obsessive-compulsive & related disorders ◼ Panic disorders ◼ Phobias ◼ Post-traumatic stress disorder ◼ Substance-induced anxiety disorder ◼ Somatic symptom disorder 23 Etiology of Anxiety Disorders ◼ Biological factors ◼ Social factors ◼ Psychological factors ◼ Environmental factors ◼ ◼ ◼ ◼ ◼ ◼ Genetics, neurobiological theories Traumatic life events Psychodynamic, learning theories Prenatal toxic exposure Adverse childhood events Sociocultural factors ◼ Culture bound syndromes 24 8 10/4/2023 Panic Disorder ❖ ❖ ❖ Panic attacks are the key feature of a panic disorder Repeated panic attacks that increase in duration & intensity over a period of 1-2 months meets the diagnostic criteria for panic disorder May or may not be also associated with Agoraphobia 25 Panic Attack ❖ ❖ ❖ ❖ ❖ Discrete periods of fear or discomfort (10-30 min.) Come “out of the blue” Physical sensations of: Accelerated HR, cold sweat, feeling of choking, SOB, derealization, depersonalization, fear of dying/losing control, numbness, tingling Causes concern/fear of when another one will occur Clients commonly present in ER before being diagnosed with Panic Disorder 26 27 9 10/4/2023 Clinical Course of Panic Disorder ❖ ❖ ❖ ❖ Lifelong disorder, peaks in late teens/early 20’s, & then again in the 30’s Can be a chronic condition that has several exacerbation & remissions during the course of the disease Characterized by disabling attacks of panic that lead to other symptoms, such as phobias Can be comorbid with agoraphobia (most severe, women more likely), social anxiety/phobia due to client using avoidance behaviors to decrease anxiety 28 Etiology of Panic Disorders ❖ ❖ ❖ ❖ Substantial Genetic Predisposition (up to 5x’s in 1st degree relatives) Environmental Factor Dysfunctional signaling found in the fear network of the brain, e.g., Amygdala & Hippocampus Dysregulation in Norepinephrine (stimulates the physical sensations) & also low levels of Serotonin have been implicated 29 Psychodynamic Theories ❖ Possible commonalities of background & personality traits: ❖ ❖ Seen in children i.e., with being more prone to fearfulness, modeling parental behaviors, increase in separation anxiety = reaction to stress & sx’s in 20’s Cognitive-Behavioral theories: ◼ ◼ ◼ Fear response is learned Catastrophic interpretation Misinterpretation of mild physical sensations 30 10 10/4/2023 Risk Factors ➢ ➢ ➢ ➢ ➢ ➢ Family History Substance & stimulant use or abuse Undertaking severe stressors Genetic predisposition Female gender For children: Physical or sexual abuse 31 Nursing Management: Biological Domain Assessment: 32 Nursing Management: Biological Domain Assessment: ✓ Self-assessment ✓ Ruling out of other disorders ✓ General assessment of symptoms (rating scales) ✓ Careful review of events prior to attack ✓ Substance use ✓ Sleep patterns ✓ Physical activity 33 11 10/4/2023 Nursing Interventions: Biological Domain 34 Nursing Interventions: Biological Domain ➢ Breathing control: Reduce hyperventilation & interrupt a panic attack; Takes practice ➢ Nutritional planning: Hypoglycemic events, caffeine intake ➢ Relaxation techniques: Progressive muscle-relaxation exercises to “get out of their own heads” 35 Psychopharmacologic Treatment ❖ Antidepressants: ◼ ◼ ◼ SSRI’s- Paroxetine, Sertraline SSNRI’s- Duloxetine, Venlafaxine TCA’s ❖ Anxiolytics: ❖ Beta blockers: ◼ ❖ ❖ ❖ Benzodiazepines- Alprazolam, Lorazepam Propanolol Useful for performance anxiety Teaching Points: ◼ Avoid OTC meds, consider sedative effects, avoid alcohol, do not abruptly discontinue medication 36 12 10/4/2023 Drugs Used to Treat Anxiety ◼ Barbiturates ◼ ◼ ◼ ◼ ◼ -barbital’s  GABA channel opening duration Death in overdose Should never be prescribed for psychiatric purposes Benzodiazepines ◼ ◼  GABA channel opening frequency Lower toxicity in overdose 37 Drugs Used to Treat Anxiety: Benzodiazepines ◼ ◼ Immediate & noticeable relief of anxiety symptoms Cause both psychological & physiological tolerance ◼ ◼ ◼ ◼ High potential for abuse & addiction Side effects: sedation, memory impairment, cognitive dulling, dizziness Not recommended for patients over 65 Have been shown to make anxiety & depression worse in the long term 38 Drugs Used to Treat Anxiety: Benzodiazepines -azepam’s ◼Diazepam (Valium) ◼Clonazepam (Rivotril) ◼Lorazepam (Ativan) ◼Flurazepam (Dalmane) ◼Temazepam (Restoril) ◼Nitrazepam (Mogadon) ◼Oxazepam (Serax) -azolam’s ◼Alprazolam (Xanax) ◼Triazolam (Halcion) 39 13 10/4/2023 Drugs Used to Treat Anxiety: Benzodiazepines ◼ Short-acting benzo’s ◼ Hypnotics to induce sleep ◼ Sedation can be rapidly withdrawn ◼ ◼ Long-acting benzo’s ◼ ◼ ◼ Triazolam, oxazepam, midazolam Diazepam, chlordiazepoxide (Librium) Librium good for ETOH detox Intermediate-acting benzo’s ◼ ◼ Most common Lorazepam, clonazepam, alprazolam, temazepam 40 Keep in Mind ◼ ◼ Psychotherapy should be 1st line treatment for anxiety Benzo’s should only be used short-term 41 Nursing Management: Psychological Domain Assessment: 42 14 10/4/2023 Nursing Management: Psychological Domain Assessment: ✓ ✓ ✓ ✓ ✓ Suicide assessment Patterns of panic attacks, symptoms & responses Mental Status Exam- Restlessness, irritability, watchful or worried facial expression, decreased attention span, difficulty problem solving, helplessness Cognitive thought patterns, avoidance behaviors Self-concept 43 Nursing Interventions: Psychological Domain When Panic Strikes: ➢ Stay with the client ➢ Reassure him/her that you will not leave ➢ Give clear directions, use short-sentences ➢ Assist client to an environment with minimal stimulation ➢ Walk with the client ➢ Administer PRN anxiolytic medications ➢ Work with client on deep breathing exercises 44 Clinical Picture: Other AD’s ◼ Separation anxiety disorder ◼ ◼ Agoraphobia ◼ ◼ Developmentally inappropriate levels of concern over being away from a significant other Excessive anxiety or fear about being in places or situations from which escape might be difficult or embarrassing Specific phobias 45 15 10/4/2023 Clinical Picture: Other AD’s (cont.) ◼ Social anxiety disorder ◼ ◼ Severe anxiety or fear provoked by exposure to a social or a performance situation that will be evaluated negatively by others Other anxiety disorders ◼ ◼ Substance-induced anxiety disorder Anxiety due to a medical condition 46 Generalized Anxiety Disorder (GAD) ❖ Essential features: Excessive anxiety & worry occurring more days than not for at least 6 months ❖ ❖ ❖ ❖ ❖ Persistent & exaggerated Obsessive worry interferes with daily functioning Very common: 10% will experience it in their lifetime Affects women 2X as often Comorbid with depression & also associated with substance use 47 “What if’s…” 48 16 10/4/2023 GAD Etiology ➢ ➢ ➢ Neurochemical theories: Little research Genetic theories: Moderately inherited Psychological theories: ◼ ◼ ➢ Inaccurate assessment of environment Selective focus on negative details, distorted information, overly pessimistic view Social theories: ◼ ◼ High-stress lifestyle Multiple stressful events 49 50 Nursing Management: Biologic Domain Assessment: ✓ Diet & Nutrition ✓ ✓ may be hypersensitive to caffeine Sleep Patterns ✓ Sleep disturbances are common 51 17 10/4/2023 Psychopharmacologic Treatment Benzodiazepines: Are no longer the 1st drug of choice ❖ Non-Benzodiazepines: Buspirone ❖ Antidepressants: SSRI’s & SSNRI’s are now the mainstay for ❖ treatment 52 Nursing Management: Psychosocial Domain Assessment: Similar for those with panic disorder: ➢ ➢ On MSE, will note that the anxiety is always out of proportion to the event/situation Common symptoms are restlessness, fatigue, poor concentration, irritability, tension Interventions: similar for those with panic disorder: ➢ ➢ Cognitive Psychotherapy is effective for Tx of GAD Outcomes include reducing frequency & intensity of anxiety, & controlling factors that contribute to anxiety 53 Obsessive Compulsive Disorder (OCD) Now has it’s own chapter in the DSM 5 ❖ Severe obsessions or compulsions that interfere with daily functioning ❖ 54 18 10/4/2023 Obsessive-Compulsive Disorders ◼ Obsessions ◼ ◼ ◼ Unwanted, intrusive thoughts, impulses, or images that persist & recur, & cannot be dismissed from the mind Thoughts cause anxiety & distress Compulsions ◼ Ritualistic behaviours an individual feels driven to perform repeatedly in an attempt to reduce anxiety ◼ Anxiety can increase when compulsive behaviours or rituals are interrupted or stopped 55 Obsessive-Compulsive Disorders (Cont.) ◼ ◼ ◼ ◼ ◼ Obsessive-compulsive disorder Body dysmorphic disorder Hoarding disorder Hair pulling & skin picking disorders Other compulsive disorders 56 Epidemiology of OCD ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ Occurs on a continuum 4th most common psychiatric illness 2.5% lifetime prevalence in adults Typical age of onset is bimodal (10 years & 21 years) Childhood OCD diagnosed almost 3X as frequently in boys than girls Occurs in adults with equal frequency in women & men Males generally have an earlier onset than females Prevalence increase with 1st degree relatives 57 19 10/4/2023 Comorbidity ◼ ◼ Commonly co-occurs with other psychiatric conditions with symptoms of rumination (mood disorder) & worry (anxiety disorder) Psychotic disorders may also occur, but people with only OCD are able to recognize that their thoughts are irrational, although they cannot control them 58 Etiology of OCD ❖ ❖ ❖ Genetic Noted abnormalities in frontal cortex, limbic system, & basal ganglia Behavioral theories: ❖ Possibly also a learned behavior, e.g., Rituals decrease anxiety & provide a primary gain 59 Clinical Picture of OCD ❖ Obsessions create anxiety, & the compulsions are performed to reduce anxiety ❖ ❖ Most common obsession is fear of contamination Common compulsions: ✓ ✓ ✓ Washing, cleaning, checking, counting, repeating actions Ordering, making confessions & seeking assurances If sequence is disturbed, person experiences anxiety 60 20 10/4/2023 61 Nursing Management: Biologic Domain Assessment: ✓ Assessment for multiple physical symptoms ✓ Physical fears ✓ Physical consequences of compulsions ✓ Nutrition & sleep status ✓ Dermatologic lesions secondary to hand washing 62 Psychopharmacologic Treatment ❖ Antidepressants: ◼ ◼ SSRI’s- Fluvoxamine, Fluoxatine, Paroxetine, Sertraline TCA’s- Clomipramine ◼ ❖ Gold standard for OCD Teaching Points: Do not stop prescribed medication abruptly, avoid OTC medications, consider sedative effects 63 21 10/4/2023 Nursing Management: Psychological Domain Assessment: ✓Monitor for suicide assessment ✓Type & severity of obsessions & compulsions ✓Degree to which the OCD symptoms interfere with client’s daily functioning ✓Consider using rating scales 64 Nursing Interventions: Psychological Domain Priority Care Issues: ➢ When in hospital, monitor for suicide risk secondary to intrusive thoughts ➢ Be non-judgmental & supportive ➢ Be realistic in your expectations, these are clients that are fixed & rigid in their behaviors 65 Nursing Interventions: Psychological Domain Priority Care Issues: ➢ Unit routines need to be clearly explained to decrease fear of the unknown ➢ Assist client in arranging schedule ❖ In Out-Patient: Client will learn other methods of cognitive restructuring, thought stopping, exposure therapy & psychoeducation 66 22 10/4/2023 Nursing Process & Anxiety Disorders ◼ Assessment ◼ ◼ ◼ ◼ ◼ General assessment of symptoms: Cognitive, affective, physiologic, & behavioural Hamilton Rating Scale for Anxiety (table 12-9) Self-assessment Assessment guidelines: Anxiety disorders (p. 219) Nursing diagnosis (Table 12-11) 67 Application of the Nursing Process (cont.) Outcomes identification (Table 12-14) ◼ Planning ◼ ◼ ◼ In hospital or community Involve client with mild to moderate levels of anxiety 68 Goals of Treatment ➢ Common goals for clients with anxiety include: ➢ ➢ ➢ The client will use effective coping strategies The client will report a decreased intensity of anxiety The client will use breathing techniques to control anxiety & hyperventilation 69 23 10/4/2023 Implementation ➢ Alleviating Anxiety: ➢ ➢ ➢ ➢ ➢ Initiating a therapeutic dialogue Countering faulty thinking Managing hyperventilation Suggesting lifestyle changes Teaching adaptive coping strategies: ➢ Relaxation techniques, visualization, teaching problem-solving strategies 70 Implementation (cont.) ✓ ✓ Mild to moderate levels of anxiety (Table 12-15) Severe to panic levels of anxiety (Table 12-16) ❖ Pharmacological interventions ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ Antidepressants Anxiolytics Psychobiological interventions Health Teaching Counselling Teamwork & safety Promotion of self-care activities Connecting to Community Resources & referrals to Interdisciplinary Team Members 71 Advanced-Practice Interventions   Cognitive therapy Behavioural therapy Relaxation training Modelling ➢ Systematic desensitization ➢ Flooding ➢ Response prevention ➢ Thought stopping • Cognitive-behavioural therapy ➢ ➢ 72 24 10/4/2023 Community Resources ❖ ➢ ➢ ➢ ❖ ➢ ➢ ➢ ➢ ➢ Self-Help: Anxiety Disorders Association of Manitoba www.adam.mb.ca Obsessive Compulsive Disorder Centre Manitoba Operational Stress Injury Social Support Counselling: Manitoba Psychological Society Klinic Drop-In Counselling Service Aurora Family Therapy Centre Psychological Service Centre at U of M Anxiety Disorders Clinic at St. Boniface Hospital (Doctor referral is needed) 73 Trauma & Stressor-Related Disorders Acute stress disorder ◼ Post-traumatic stress disorder (PTSD) ◼ Dissociative disorders ◼ 74 Acute Stress Disorder ◼ ◼ Occurs within 1 month of a highly traumatic event (resolving in 4 weeks) At least 3 dissociative symptoms present: ◼ A subjective sense of numbing, detachment, or absence of emotional responsiveness A reduction in awareness of surroundings Derealization ◼ Depersonalization ◼ Dissociative amnesia ◼ ◼ ◼ ◼ A sense of unreality related to the environment A sense of unreality or self-estrangement 75 25 10/4/2023 Post-Traumatic Stress Disorder (PTSD) ❖ ❖ ❖ An acute emotional response that develops following a direct, indirect, or witnessed exposure to an extreme stressor or traumatic event Now included in a new chapter in the DSM-5 under Trauma & Stressor-related disorders Can also occur when an Acute Stress Disorder has not been resolved 76 PTSD ◼ Major features of PTSD are persistent: ◼ ◼ ◼ ◼ ◼ Re-experiencing of the trauma through recurrent intrusive recollections Flashbacks Avoidance of stimuli associated with the trauma Numbing of general responsiveness Increased arousal: irritability, difficulty sleeping, difficulty concentrating, hypervigilance, or exaggerated startle response 77 Risk Factors ➢ Persons at risk: ➢ ➢ ➢ ➢ Survivors of severe trauma, survivors of genocide Police, firefighters, emergency personal Anyone involved in a disaster e.g., Boston Marathon Reciprocal stress: PTSD in one family member=stress in whole family 78 26 10/4/2023 Clinical Picture: PTSD ❖ ❖ ❖ ❖ PTSD can present after any traumatic event that is outside of the range of usual experiences It can occur within 3 months of the event, also can see a delayed response, e.g., years later The client will persistently re-experience a traumatic event that involved a threatened or actual death or serious injury to self or others The response to the event involved intense fear, helplessness or horror 79 3 Key Symptom Dimensions of PTSD ❖ Symptom 1: Re-experiencing ✓ ✓ ✓ ✓ ✓ Intrusive images, thoughts, perceptions Recurrent dreams Illusions, hallucinations Flashbacks Intense distress when exposed to the cues that remind the client of the event 80 PTSD Symptoms (Cont.) ❖ Symptom #2: Avoidance ✓ ✓ ✓ ✓ Avoidance of thoughts, feelings, conversations, activities, places or people that will serve as a trigger to anxiety Disassociation - unable to recall an important aspect of the trauma Feeling detached (depersonalization) Restricted affect, emotional numbing, feeling empty 81 27 10/4/2023 PTSD Symptoms (Cont.) ❖ Symptom # 3: Hyperarousal ✓ ✓ ✓ ✓ ✓ ✓ ✓ Stress system goes on permanent alert Dopamine hyperactivity Difficulty falling asleep or staying asleep Irritability Difficulty concentrating Hypervigilance Exaggerated startle response 82 Clinical Picture of PTSD (Cont.) ❖ Areas of concern: Risk for suicide & homicide Child & spousal abuse ✓ Substance Abuse ✓ Ineffective maintenance of interpersonal, social or occupational relationships & responsibilities ✓ ✓ 83 Treatment Goals & Resources ❖ ❖ ❖ ❖ Anxiety management Education Individual Psychotherapy Psychopharmacology ❖ ❖ ❖ ❖ ❖ Prazosin (anti-hypertensive) Used in treating nightmares associated with PTSD  risk of orthostatic hypotension Group Therapy Family Therapy 84 28 10/4/2023 Dissociative Disorders ▪ ▪ ▪ ▪ Occur after significant adverse experiences or traumas Individuals respond to stress with severe interruption of consciousness Unconscious defense mechanism Protects individual against overwhelming anxiety through emotional separation 85 Dissociative Disorders (Cont.) ▪ ▪ ▪ ▪ Depersonalization/derealization disorder Dissociative amnesia Dissociative fugue Dissociative identity disorder 86 What is Dissociation? ◼ ◼ Symptoms can potentially disrupt every area of psychological functioning DDs are characterized by a disruption of &/or discontinuity in the normal integration of: • Consciousness, memory, identity, emotion, perception, body representation, motor control, & behaviour 87 29 10/4/2023 What is Dissociation? (cont.) Dissociative symptoms are experienced as: ◼ a) b) Unbidden intrusions into awareness & behaviour, with accompanying losses of continuity in subjective experience (i.e., ‘‘positive’’ dissociative symptoms such as fragmentation of identity, depersonalization, and derealization) &/or Inability to access information or to control mental functions that normally are readily amenable to access or control (i.e., “negative’’ dissociative symptoms such as amnesia) 88 Dissociative Disorders (Cont.) ▪ Epidemiology: ▪ Controversial: Some sources say rare, but: ▪ ▪ ▪ ▪ Depersonalization: 1-3% of population Dissociative amnesia: 2-7% of population Co-morbidities of anxiety & depression are extremely common Etiology: Bio-psycho-social factors, diathesis-stress model 89 Dissociative Disorders (Cont.) ▪ Biological factors ▪ ▪ ▪ ▪ ▪ Genetics Trauma-induced neurobiological changes in the brain Psychological factors: Learned stress-avoidance Environmental factors: Exposure to traumatic events Cultural considerations: Rule out culture-bound disorders 90 30 10/4/2023 Depersonalization/Derealizatio n Disorders ▪ Depersonalization ▪ ▪ Focus on self Derealization ▪ Focus on outside world 91 Depersonalization Disorder ◼ ◼ ◼ ◼ Persistent or recurrent experiences of feeling detached from, & as if one is an outside observer of one’s mental processes or body (e.g., feeling like one is in a dream) Reality testing remains intact Causes clinically significant distress or impairment Not due to substance use or medical condition 92 Derealization Disorder ◼ Persistent or recurrent experience of unreality of surroundings ◼ ◼ ◼ E.g., the world around the individual is experienced as unreal, dreamlike, distant, or distorted Causes clinically significant distress or impairment Not due to substance use or medical condition 93 31 10/4/2023 Dissociative Amnesia Formerly called “Psychogenic amnesia” Inability to recall important personal information, usually of a traumatic or stressful nature, that is too extensive to be explained by ‘ordinary’ forgetting Not due to the effects of a substance or medical condition Sx cause clinically significant distress or impairment in social, occupational, or other important areas of functioning ▪ ▪ ▪ ▪ 94 Dissociative Fugue ◼ ◼ ◼ ◼ ◼ ◼ Formerly “Psychogenic Fugue” Sudden, unexpected travel away from the customary locale Inability to recall one’s identity & some or all of the past Confusion about personal identity or assumption of a new identity (complete or partial) When former identity is remembered, become amnestic for time spent in fugue Sx cause distress or impairment in functioning, & are not due to substance use or medical condition 95 Dissociative Identity Disorder (DID) ▪ ▪ ▪ Disruption of identity characterized by 2 or more distinct personality states The disruption of identity involves marked discontinuity in the sense of self & sense of agency, accompanied by related alterations in affect, behaviour, consciousness, memory, perception, cognition, &/or sensory-motor functioning These S&Sx may be observed by others or reported by the patient 96 32 10/4/2023 DID (cont.) There are recurrent gaps in the recall of everyday events, important personal information, &/or traumatic events that are inconsistent with ‘ordinary’ forgetting Sx cause clinically significant distress or impairment in social, occupational, or other areas of functioning Not a normal part of a broadly accepted cultural or religious practice Not attributable to the physiologic effects of a substance or other medical condition ▪ ▪ ▪ ▪ 97 DID (cont.) ▪ ▪ Primary personality (host) usually not aware of alters Each alternate personality (alter) has own pattern of ▪ ▪ ▪ Perceiving Relating to Thinking about the self & environment 98 Dissociative Disorders Assessment ▪ ▪ ▪ ▪ ▪ Suicide risk History Moods Impact on patient & family Self-assessment 99 33 10/4/2023 Dissociative Disorders Implementation ▪ Interventions ▪ ▪ ▪ Advanced-practice interventions ▪ ▪ Psychoeducation Pharmacological interventions Somatic therapy Evaluation 100 QUESTIONS? 101 34