Chapter 27

1. 1:2 2. 1:4 3. 1:8 4. 1:12

1. Depression 2. Anxiety Disorders 3. Bipolar Disorder 4. Substance Abuse

 Fear  Reaction to a specific danger  Anxiety  Feeling of apprehension, uneasiness, uncertainty, or dread resulting from a real or perceived threat whose actual source is unknown or unrecognized  Vague sense of dread r/t an unspecified danger.

 Mild – tension of everyday life, alert, perceptual field increased  Moderate – narrowing perceptual field  Severe – significant reduction in perceptual field

 Most common of the psychiatric illnesses  Women experience anxiety disorders more often than men  At high risk are smokers, individuals younger than 45 years, those separated or divorced, survivors of abuse, and those in low socioeconomic groups  Affect individuals of all ages  Tend to be chronic and persistent illnesses

 Genetic theories  Biochemical theories  Serotonin and norepinephrine  Gamma-aminobutyric acid  Hypothalamus–pituitary–adrenal (HPA) axis  Neuroanatomic theories  Psychoanalytic and psychodynamic theories  Cognitive behavioral theories

 Panic  A normal but extreme, overwhelming form of anxiety often experienced when an individual is placed in a real or perceived life-threatening situation  Panic attacks  Sudden, discrete periods of intense fear or discomfort that are accompanied by significant physical and cognitive symptoms  Panic disorder  A chronic condition that has several exacerbations and remissions during the course of the disease  Characterized by panic attacks that often lead to other symptoms, such as phobias

 Panic attack:  Periods of intense fear, at which time at least four physical or psychological symptoms are manifested:  Palpitations, pounding heart, accelerated heart rate, sweating, shaking, shortness of breath or smothering, sensations of choking, chest pain, nausea or abdominal distress, dizziness, derealization, fear of going crazy, fear of dying, paresthesias, and chills or hot flashes  Panic disorder:  Recurrent and unexpected panic attacks, followed by 1 month or more of consistent concern about having another attack, worrying about the consequences of having another attack, or changing behavior because of fear of the attacks

 Phobias  Persistent, unrealistic fears of situations, objects, or activities  Agoraphobia  Fear of open spaces, commonly co-occurs with panic disorder  DSM-5 Criteria in Box 27-1 (pg 533)

 Family history  Substance and stimulant use or abuse  Smoking tobacco  Severe stressors  Female gender  Several anxiety symptoms  Separation anxiety during childhood  Early life traumas  History of physical or sexual abuse  Socioeconomic or personal disadvantages  Behavioral inhibition

 Safe and therapeutic environment  Medication and monitoring of effects  Individual psychotherapy  Psychological testing

 Biologic Domain  Rule out life-threatening medical causes  Substance use  Sleep patterns  Physical activity

 Psychological  Self-report scales  Mental status examination  Anxiety symptoms  Disorganized thinking, irrational fears, and decreased ability to communicate  Assessment of cognitive thought patterns  Catastrophic misinterpretations

 Social:  Assess family dynamics/functioning  Understand cultural competence; assess for cultural differences; some cultures see anxiety as a sign of weakness—may not admit to feeling anxious.

 Breathing control  Nutritional planning  Relaxation techniques  Increased physical activity  Pharmacologic interventions  Antidepressants  Selective serotonin reuptake inhibitors (SSRIs)  Serotonin-norepinephrine reuptake inhibitors (SNRIs)  Tricyclic antidepressants (TCAs)  Monoamine oxidase inhibitors (MAOIs)  Antianxiety medications (benzodiazepines)

 SSRIs  Produce anxiolytic effects by increasing the transmission of serotonin by blocking serotonin reuptake at the presynaptic cleft  SNRIs  Increase levels of both serotonin and norepinephrine by blocking their reuptake presynaptically  Benzodiazepines  The most commonly used medications for panic disorder even though SSRIs are recommended for first- line treatment  Therapeutic onset is much faster (hours, not weeks) than that of antidepressants  Useful in treating intensely distressed patients  Beta Blockers

1. Risperdal 2. Lithium 3. Wellbutrin 4. Lexapro

 Identifying triggers  Distraction techniques  Positive self-talk  Systematic desensitization  Implosion therapy  Cognitive-behavioral therapy (CBT)

 Stay with the patient  Reassure him/her that you will not leave  Give clear directions  Assist patient to an environment with minimal stimulation  Walk with the patient  Administer PRN anxiolytic medications

 Obsessions  Unwanted, intrusive, and persistent thoughts, impulses, or images that cause anxiety and distress  Obsessions are not under the patient’s control and are incongruent with the patient’s usual thought patterns  Compulsions  Behaviors that are performed repeatedly, in a ritualistic fashion, with the goal of preventing or relieving anxiety and distress caused by obsessions

 Criterion A: the presence of obsessions or compulsions  Criterion B: at some point in the disorder, the patient recognizes that the thoughts and actions are unreasonable or excessive  Criterion C: the thoughts and rituals cause severe disturbance in daily routines, relationships, or occupational function and are time-consuming, taking longer than 1 hour a day to complete  Criterion D: the thoughts or behaviors are not a result of another Axis 1 disorder  Criterion E: the thoughts or behaviors are not a result of the presence of a substance or a medical condition

 Link between infection with β-hemolytic streptococci and OCD  Young, divorced or separated, and unemployed  OCD appears to be less common among African Americans than among non-Hispanic Caucasians

 Biologic Domain  Multiple physical symptoms  Dermatologic lesions  Osteoarthritic joint damage

 Psychological Domain  Type and severity of obsessions and compulsions  Distracted by obsessed thoughts  Neatly dressed and groomed, cooperative, and eager to answer questions  Speech of normal rate and volume  Circumferential speech  Degree to which symptoms interfere with daily functioning

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 Maintaining skin integrity  Psychopharmacologic treatment  Antidepressants given in higher doses than for treatment of depression  Side effect monitoring a problem for those preoccupied with somatic concerns  Administering and monitoring medications  Monitoring side effects of SSRI and TCA  Monitoring for drug interactions

 Response prevention  Thought stopping  Cue cards  Distraction  Relaxation techniques  Psychoeducation

 Consider sociocultural factors and patient’s ability to relate to others  In the hospital, unit routines are carefully and clearly explained to decrease patient’s fear of unknown  Recognize significance of rituals  Assist patient in arranging schedule  Marital and family support are important

 Affects individuals of all ages  About half the individuals report onset in childhood or adolescence  May exhibit mild depressive symptoms  Highly somatic  Poor sleep habits, irritability, trembling, twitching, poor concentration, and an exaggerated startle response  A sense of ill-being and uneasiness and a fear of imminent disaster

 Criterion A: excessive worry and anxiety about several issues that occurs more days than not for a period of at least 6 months  Criterion B: the patient has little or no control over the worry  Criterion C: the anxiety and worry are accompanied by at least three of the following symptoms for at least 6 months: sleep disturbance, becoming easily fatigued, restlessness, poor concentration, irritability, and muscle tension  Criterion D: the worry and anxiety focuses are not limited to the qualities of another psychiatric diagnosis, including panic disorder, social phobia, OCD, separation anxiety disorder, anorexia nervosa, somatization disorder, or hypochondriasis, and do not exclusively occur with PTSD  Criterion E: the worry and anxiety cause significant impairment in social, occupational, or another significant area of functioning  Criterion F: the disturbance is not substance-induced or caused by a general medical condition and does not occur exclusively with a mood, psychotic, or pervasive developmental disorder

 Unresolved conflicts  Cognitive misinterpretations  Life stressors  Genetic predisposition  Behavioral inhibition

 Diet and nutrition  May be hypersensitive to caffeine  Sleep patterns  Disturbances common  Substance use

 Medications  Buspirone (BuSpar)  Antidepressants  Nutrition counseling  Sleep hygiene

 Assessment and interventions are similar to those for panic disorder  Combination of:  Relaxation  Supportive therapies  Cognitive therapies (CBT)

 Specific phobia  Social phobia  PTSD  Acute stress disorder  SAD

 Repeated re-experiencing of a traumatic event  actual or threatened death or serious injury (to self or others)  Intense fear, helplessness, or horror  Symptoms begin 3 months after trauma  Symptoms  Flashbacks, persistent avoidance of stimuli associated with trauma, general numbing of general responsiveness, hypervigilance

 Occurs within one month after exposure to a highly traumatic event  Must display at least three dissociative symptoms  Resolves within 4 weeks  After a month, changes to PTSD