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Anxiety, Anxiety
Disorders and Stress-
Related Illness
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ANXIETY
This is a vague feeling of dread orapprehension; it is a response to external and
internal stimuli that can have behavioral,
emotional, cognitive and physical symptoms.
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ANXIETY DISORDERS
-comprise a group of conditions that share a
key feature of excessive anxiety with ensuringbehavioral, emotional, cognitive and
physiologic responses.
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ANXIETY AS A RESPONSE TO STRESS
Stress is the wear and tear that life causes on the
body
Han Selye, an endocrinologist, identified the
physiologic aspects of stress, which he labeled the
general adaptation syndrome
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Alarm reaction stage- Stress stimulates the body to send
message from the hypothalamus tothe glands and organs to prepare for
potential defense needs.
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Resistance Stage
- The digestive system reduces function to shunt
blood to areas needed for defense. Lungs take in
more air, and the heart beats faster and harder so it
can circulate this highly oxygenated and highly
nourished blood to the muscles to defend the body
by fight, flight or breeze behaviors.
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Exhaustion stage
- Occurs when the person responded negatively
to anxiety and stress: body stores are depleted or
the emotional components are not resolved,
resulting in continual arousal of the physiologic
responses and little reserve capacity.
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LEVELS OF NXIETYAnxiety Level Psychological
Responses
Physiologic Responses
Mild Wide perceptual field
Sharpened senses
Increased motivation
Increased learning
ability
Irritability
Restlessness
Fidgeting
GI butterflies
Difficulty sleeping
Hypersensitivity to
noise
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Moderate Perceptual field narrowed
to immediate task
Selectively attentiveCannot connect thoughts
or events independently
Increased use ofautomatisms
Muscle tension
Diaphoresis
Pounding pulseHeadache
Dry mouth
High voice pitchFaster rate of speech
GI upset
Frequent urination
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Severe Perceptual field reduced to
one detail or scattered details
Cannot complete tasks
Cannot solve problems orlearn effectively
Behavior geared toward
anxiety relief and is usually
ineffective
Doesnt respond to redirection
Feels awe, dread, or horror
Cries
Ritualistic behavior
Severe headache
Nausea, vomiting and
diarrhea
TremblingRigid stance
Vertigo
Pale
Tachycardia
Chest pain
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Panic Perceptual field reduced to focus
on self
Cannot process any environmental
stimuliDistorted perceptions
Loss of rational thought
Doesnt recognize potential
danger
Cant communicate verbally
Possible delusions and
hallucination
May be suicidal
May bolt and n
OR
Totally immobile and mute
Dilated pupilsIncreased blood pressure
and pulse
Fight, flight, or freeze
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Working with Anxious Clients
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Mild anxiety is asset to the clients and requires
no direct intervention.
Moderate anxiety, the nurse must be certain
that the client is following on what the nurse issaying. The clients attention can wander, and he or
she may have some difficulty concentrating over time.
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When anxiety becomes severe, the client no
longer can pay attention or take information. The nurse
goals must be lower the persons anxiety level to
moderate or mild before proceeding with anything else.
Talking to the client in a low, calm and soothing voice
can help. If the person cannot sit still, walking with
them while talking can be effective.
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During the panic level anxiety, the persons safety is
the primary concern. The nurse must keep talking to the
person in a comforting manner, even though the client
cannot process what the nurse is saying. Going to small,
quiet, and non stimulating environment may help to reduce
anxiety. The nurse should remain with the client until the
panic recedes. Panic level is not sustained independently but
can last from 5- 30 minutes.
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when working with an anxious client,
the nurse must be aware of his or err own
anxiety level..it is easy for the nurse to
become increasingly anxious. Remainingcalm and in control is essential if the nurse
is going to work effectively with the client
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Short term anxiety can be treated with anxiolytic
medications. Most of these are Benzodiazepines, which
are commonly prescribed for anxiety. These drug are
designed to relieve anxiety so that the person can dealmore effectively with whatever crisis or situation is
causing stress
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Stress related illness
Is a broad term that covers a spectrum of illnesses that result from or
worsen because of chronic, long term, or unresolved stress
Chronic stress that is repressed can cause eating disorders, such s
anorexia nervosa and bulimia.
Stress can also exacerbate the symptoms of many illnesses, such as
hypertension and ulcerative colitis
Chronic or recurrent anxiety resulting from stress may also be
diagnosed as an anxiety disorder
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ANXIOLYTIC DRUGS
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BENZODIAZEPINES
Diazepam (valium)
Alprazolam(xanax)
Chlordiazepoxide(librium)
Lorazepam(ativan)Clonazepam(klonopin)
Oxazepam(serax)
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NON-BENZODIAZEPINES
Buspirone(buspar)
Meprobamate(miltown,equanil)
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Implementation
NURSINGINTERVENTION
Remain w/ the client atall the times when levels
of anxiety are high.Move the client to a quiet
area w/ minimaldecrease stimuli such as
a small room.
RATIONALE
A highly anxious clientshould not be alone.
In a large area, the clientcan feel lost andpanicked, but a smaller
room can enhance asense of security.
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Cont
PRN medications may beindicated for high levelsof anxiety , delusions,disorganized thoughts
and so forth.
Remain calm in yourapproach to the client.
Medications may benecessary to decreaseanxiety to a level at w/cthe client can feel safe.
The client can feel moresecured if you are calm
and if the client feels youare in control of thesituation.
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Cont
Use short simple andclear statements.
Avoid asking or forcing
the client to makechoices.
Be aware of your own
feelings in level ofdiscomfort.
The client ability to dealw/ abstractions orcomplexity is impaired.
The client may not make
sound decisions or maybe unable to makedecisions.
Anxiety is communicated
interpersonally. Being w/an anxious client can rise
your own anxiety level.
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Cont
Encouraged the clientparticipation inrelaxation exercise such
as deep breathing,progressive musclerelaxation ,meditation ,and imagining being in a
quiet and peaceful place.
Relaxation exercise areeffective, non chemical
ways to reduce anxiety.
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Cont
Teach the client to userelaxation techniquesindependently.
Help the client see thatmild anxiety can be apositive catalyst for
change and does notneed to be avoided.
Using relaxationtechniques can give theclient confidence inhaving control over
anxiety.
The client may feel thatall anxiety is bad and not
useful.
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OVERVIEW OF ANXIETY
DISORDERS
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Anxiety disorders are diagnosed when anxiety
no longer function as a signal of danger or a
motivation for needed change but becomes chronic
and permeates major portions of the persons life,
resulting in maladaptive behaviors and emotional
disability.
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Types of anxiety disorders include the following;
Agoraphobia with or without panic disorder Panic disorder
Specific phobia
Social phobia
OCD Generalized anxiety disorder (GAD)
Acute stress disorder
Posttraumatic stress disorder.
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RELATED DISORDER
Anxiety disorder due to a general medical
condition
-diagnosed when the prominent symptoms of
anxiety are judged to result directly from a
physiologic condition. The person may have panicattacks, generalized anxiety, or obsessions or
compulsions.
Subtance-induced anxiety disorder
-is anxiety directly caused by drug abuse,
medication, or exposure to a toxin .Symptoms
include prominent anxiety, panic attacks, phobias,
obsession, or compulsions
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Separation anxiety disorder
-is excessive anxiety concerning separation
from home or from person, parents, or caregivers towhom the clients is attached. It occurs when it is no
longer developmentally appropriate and before 18
years of age.
Adjustment disorder-is an emotional response to a stressful event,
such as one involving financial issues, medical
illness,or a relationship problem, that result in
clinically significant symptoms such as markeddistress or impaired functioning.
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ETIOLOGY
GENETIC THEORIES
-Anxiety may have an inherited componentbecause the first-degree relatives of clients withincreased anxiety have higher rates of developing
anxiety. Heritability refers to the proportion of adisorder that can be attributed to genetic factors.
High heritabilities are greater than 0.6and indicatethat genetic influences dominate.
Moderate heritabilities are 0.3 to 0.5 and suggestan even greater influence of genetic andnongenetic factors.
Heritabilities less than 0.3 mean that genetics arenegligible as a primary cause of the disorder.
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NEUROCHEMICAL THEORIES
Gamma-aminobutyric acid (y-aminobutyric acid [GABA]is the amino acid neurotransmitter believed to be
dysfunctional in anxiety disorders. GABA , an inhibitorneurotransmitter , functions as the bodys naturalantianxiety agent by reducing cell excitability, thusdecreasing the rate of neuronal firing.
Because GABA reduces anxiety and norepinephrine
increases it, it researchers believe that a problem withthe regulation of these neurotransmitters occurs inanxiety disorders.
Serotonin, the indolamine neurotransmitter usuallyimplicated in psychosis and mood disorders, has many
subtypes. Serotonin is believed to play a distinct role inOCD, panic disorder, and GAD. An excess innorepinephrine is suspected in panic disorder, GAD, andposttraumatic stress disorder.
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PSYCHODYNAMIC THEORIES
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INTRAPSYCHIC/PSYCHOANALYTICTHEORIES
Freud (1936) saw a persons innate anxiety as the
stimulus for behavior. He described defense
mechanisms as the humans attempt to controlawareness of and to reduce anxiety. Some people
overuse defense mechanisms, which stops them
from learning a variety of appropriate methods to
resolve anxiety-producing situations.
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INTERPERSONALTHEORY
HarryStack Sullivan(1952)viewed anxiety as being
generated from problems in interpersonal
relationships. Caregivers can communicate anxiety
to infants or children through inadequate nurturing,agitation when holding or handling the child, and
distorted messages .In adults anxiety arises from
the persons need to conform to the norms and
values of his or her cultural group. The higher the
level of anxiety, the lower the ability tocommunicate and solve problems and the greater
the chance for anxiety disorders to develop.
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Hildegard Peplau (1952) understood that humans
exist in interpersonal and physiologic realms; thus,
the nurse can better help the client to achieve
health by attending to both areas. She identified the
for levels of anxiety and developed nursingintervention and interpersonal view of anxiety
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BEHAVIORALTHEORY
Behavioral theorists view anxiety as being learned
through experiences. Behaviorists believe that
people can modify maladaptive behaviors without
gaining insight into their causes. They contend thatdisturbing behaviors that develop and interfere with
a personslife can be extinguished or unlearned by
repeated experiences guided by a trained therapist.
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SYMPTOMS OF ANXIETY
DISORDERSDSM IV-TR DIAGNOSTIC CRITERIA
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DISORDER SYMPTOMS
AGORAPHOBIA is anxiety about
or avoidance of places or
situations from which escapemight be difficult or in which help
might be unavailable.
Avoids being outside alone or at
home alone, avoids traveling in
vehicles, impaired ability to work,difficulty meeting daily
responsibilities (e.g. grocery
shopping or going to
appointments); knows response is
extreme
PANIC DISORDER is
characterized by recurrent,
unexpected panic attacks that
cause constant concern. Panic
attack is the sudden onset of
intense apprehension, fearfulnessor terror associated with feelings of
impending doom.
A discrete episode of panic lasting
15 to 30 minutes with four or more
of the following, palpitations,
sweating, trembling or shaking,
shortness of breath, choking or
smothering sensation, chest painor discomfort, nausea,
derealization or
depersonalization,fear of dying or
going crazy, paresthesias, chills or
hot flashes.
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SPECIFIC PHOBIA is
characterized by significant anxiety
provoked by a specific feared
object or situation, which oftenleads to avoidance behavior.
Marked anxiety response to the
object or situation, avoidance or
suffered endurance of object or
situation; significant distress orimpairment of daily routine,
occupation, or social functioning;
adolescents and adults recognize
their fear as excessive or
unreasonable.
SOCIAL PHOBIA is characterizedby anxiety provoked by certain
types of social performance
situations, which often leads to
avoidance behavior.
Fear of embarrassment or inabilityto perform; avoidance or dreaded
endurance of behavior or situation;
recognition that response is
irrational or excessive; beliefs that
others are judging him or her
negatively; significant distress or
impairment in relationships, work
or social life, anxiety can be
severe or panic level.
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OBSESSIVE-COMPULSIVE
DISORDER involves obsessions
(thoughts, impulses, or images)
that cause marked anxietyand/or
compulsions (repetitive behaviorsor mental acts) that attempt to
neutralize anxiety.
Recurrent, persistent, unwanted,
intrusive thoughts, impulses, or
images beyond worrying about
realistic life problems; attempts to
ignore, suppress, or neutralizeobsessions with compulsions that
are mostly ineffective; adults and
adolescents recognized that
obsessions and compulsions are
excessive and unreasonable.
GENERALIZED ANXIETY
DISORDER is characterized by at
least 6 months of persistent and
excessive worry and anxiety.
Apprehensive expectations more
days than not for 6 months or
more about several events or
activities; uncontrollable worrying;
significant distress or impaired
social or occupational functioning;
three of the following symptoms;
restlessness, easily fatigue,
difficulty concentrating or mind
going blank, irritability, muscle
tension, sleep disturbance,
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ACUTE STRESS DISORDERis
the development of anxiety,dissociation, and other symptoms
within 1 month of exposure to an
extremely traumatic stressor, it
lasts 2 days to 4 weeks.
Exposure to traumatic event
causing intense fear, helplessness,or horror, marked anxiety
symptoms or increase arousal;
significant distress or impaired
function; persistent re-
experiencing of the event; three of
the following symptoms; sense ofemotional numbness or
detachment, feeling dazed,
derealization, depersonalization,
dissociative amnesia (inability to
recall important aspect of the
events)
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POST TRAUMATIC STRESS
DISORDER is characterized by
the re-experiencing of anextremely traumatic event,
avoidance of stimuli associated
with the event, numbing of
responsiveness, and persistent
increased arousal; it begins within
3 months to years after the eventand may last a few months or
years.
Exposure to traumatic event
involving intense fear,
helplessness, or horror, re-experiencing (intrusive
recollections or dreams,
flashbacks, physical and
psychological distress over
reminders of the event); avoidance
of memory provoking stimuli andnumbing of generalresponsiveness
(avoidance of thoughts, feelings
conversations, people, places,
amnesia, diminish interest
participation in life events, feeling
detached or estranged from
others, restricted affect, sense of
foreboding)
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Treatment Treatment for anxiety disorders usually involves
medication and therapy.
Positive Reframing means turning negative messages intopositive messages.
Decatastrophizinginvolves the therapists use of questionsto more realistically appraise the situation
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Assertiveness Training helps the person take
more control over life situations. Techniques
help the person negotiate interpersonal
situations and foster self- assurance.
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Elder Considerations
Anxiety that starts for the first time in late life is frequentlyassociated with another condition such as depression, dementia,
physical illness, or medication toxicity or withdrawal.
Ruminative thoughts are common in late- life depression and cantake the form of obsessions such as contamination fears, pathologic
doubt, or fear of harming others.
The treatment of choice for anxiety disorder in elderly is selective
serotonin reuptake inhibitor (SSRI) antidepressants.
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Mental Health PromotionTips for managing stress:
Keep a positive attitude and believe in yourself
Accept there are events you cannot control
Communicate assertively with others
Learn to relax Exercise regularly
Eat well- balanced meals
Limit intake of caffeine and alcohol
Get enough rest and sleep
Set realistic goals and expectations and find an activity that is personally meaningful
Learn stress management techniques
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General Appearance and Motor Behavior
Mood and Affect
Thought Processes and Content
Sensorium and Intellectual Processes Judgment and Insight
Self- concept
Roles and Relationships
Physiologic and Self- care Concerns
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The client is anxious, worried, tense, depressed,
serious, or sad. When discussing the panic attacks,
the client may be tearful.
During panic attack, the client may describefeelings of being disconnected from himself or
herself (depersonalization) or sensing that things are
not real (derealization).
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The client is overwhelmed, believing that he or she is
dying, losing control or going insane. It may evenconsider suicide.
Thoughts are disorganized and the client loses the ability
to think rationally.
The client may become confused and disoriented.
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He or she cannot take in environmental cues
and respond appropriately.
The client believe they are helpless and have
no control over their anxiety attacks.
The clients often make self- blaming
statements.
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The client find themselves consumed with
worry about impending attacks and may be
unable to do many things they did before.
The person typically avoids people, places andevents associated with previous panic attacks.
The client often reports problems withsleeping and eating.
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Nursing Interventions
For Panic Disorder Provide a safe environment and ensure clients privacy during a panic
attack.
Remain with the client during a panic attack.
Help client to focus on deep breathing.
Talk to client in calm, reassuring voice.
Teach client to use relaxation technique.
Help client to use cognitive restructuring techniques. Engage client to explore how to decrease stressors and anxiety-
provoking situations.
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Client/ Family Education
For Panic Disorder Review breathing control and relaxation techniques.
Discuss positive coping strategies.
Encourage regular exercise.
Emphasize the importance of maintaining prescribed medicationregimen and regular follow- up.
Describe time- management.
Stress the importance of maintaining contact with community andparticipating in supportive organizations.
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PANICDISORDER
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Composed of discrete episodes of panic attacks,15-30 minutes of rapid, intense, escalating
anxiety in which the person experiences great
emotional fear as well as physiologic
discomfort.
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During the attack the person displays four or more
symptoms:
Palpitations, Sweating
Tremors, SOBSense of suffocation, Nausea
Chest pain Paresthesias
Chills or hot flashes DizzinessAbdominal distress
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Panic disorder is more
common in people who have
not graduated from college andare not married
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CLINICAL COURSE It peaks in late adolescence and id-30s
The person becomes homebound or stays in a limited area near
home such as on the block or within town limits. This behavior
is known as agoraphobia (fear of the marketplace or fear ofbeing outside)
The behavior pattern of people with agoraphobia clearly
demonstrate the concepts of primary and secondary gain
associated with many anxiety disorders
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Primary gain
- The relief of anxiety achieved by performing the specific
anxiety-driven behavior such as staying in the house to
avoid the anxiety of leaving a safe place.
Secondary gain
- The attention received from others as a result of these
behavior
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If the client is anxious, speech may increase in rate,pitch, and volume, and he or she may have
difficulty sitting in a chair.
Automatisms- are automatic, unconscious
mannerisms- may be apparent.
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PHOBIA
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An illogical, intense, and persistent fear of a specificobject or a social situation that causes extreme distress
and interferes with normal functioning.
Usually do not result from past negative experiences.
Person may never have had contact with the object of the
phobia.
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THREE CATEGORIES
Agoraphobia
Specific phobia
Social phobia
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AGORAPHOBIA
Fear of being in open spaces and
situation in which the person thinksthere is no escape or help would be
difficult to obtain.
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SPECIFIC PHOBIA
An irrational fear of an object or situation
Are subdivided into following categories:
> Natural environment phobias: fear of storms, water,heights or other natural phenomena
> Blood injection phobias: fear of seeing ones own
blood, traumatic injury or an invasive medical procedure
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> Situational phobias: fear of being in a specific
situation such as on a bridge or tunnel, elevator, small
room, hospital or airplane
> Animal phobia: fear of animals or insects
> Other types of specific phobias: fear of getting
lost while driving
A A
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SOCIAL PHOBIA
Also known as social anxiety disorder Which is an anxiety provoked by certain social or performance situation
The person becomes severely anxious to the point of panic or
incapacitation when confronting situations involving people.
Examples are making speech, attending social engagement alone,
interacting with opposite sex or strangers and making complaints, etc.
The fear is rooted in low self-esteem and concern about others
judgement.
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ONSET AND CLINICAL COURSE
Specific phobias usually occur in childhood oradolescence.
Social phobia peak age of onset is middle
adolescence. Sometimes emerges in a person who
was shy as a child
TREATMENT
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TREATMENT
Behavioral therapy> Systematic desensitization
> Flooding
> Positive reframing
> Assertiveness training
Therapist initially focus on teaching what anxiety is Help client identify anxiety responses
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Teach relaxation techniques
Help set goals and discuss methods to achieveit
Help client to visualize phobic situations Help client to develop self-esteem and self-
control
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Obsessions
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Are recurrent, persistent, intrusive & unwantedthoughts, images or impulses that cause markedanxiety & interfere with interpersonal, social, oroccupational function.
The persons knows these thoughts are excessive orunreasonable but believes he or she has no controlover them.
CompulsionsA i li i i i b h i l
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Are ritualistic or repetitive behaviours or mentalacts that a person carries out continuously in an
attempt to neutralize anxiety.
Usually the theme of the rituals is associated with
that of the obsession.
OCD can be manifested only when thoughts,images, & impulses consume the person or he/she iscompelled to act out the behaviours to a point atwhich they interfere with personal, social &occupational function
OCD can be manifested through many behaviours,ll f hi h i i i l & diffi l
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all of which are repetitive, meaningless & difficult toconquer .
The persons understands that these rituals areunusual & unreasonable but feel forced to perform
them to alleviate anxiety or to prevent terriblethoughts
Obsessions & compulsions are a source of distress& shame to the person, who may go to treat lengthsto keep them secret.
Onset & Clinical Course
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OCD can start in childhood, especially in males.
In females, it more commonly begins in the 20s.
Overall, distribution between the sexes is equal.
Onset is usually gradual, although there have beencases of acute onset with periods of waxing &waning symptoms.
80% of those treated with behaviour therapy andmedication report success in managing obsessions& compulsions, whereas 15% show p0rogressivedeterioration in occupational and socialfunctioning.
Treatment
Lik f th i t di d ti l t t t f OCD
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Like for other anxiety disorders, optimal treatment for OCDcombines medication & behaviour therapy.
Behaviour therapy specifically includes exposure & responseprevention:
Exposure
Involves assisting the clients to deliberately confront the
situations & stimuli that he or she usually avoids.Response Prevention
Focuses on delaying or avoiding performance of rituals. Theperson learns to tolerate the anxiety & to recognize that it will
recede without the disastrous imagined consequences.
Other techniques discussed previously, such as deep breathing& relaxation, also can assist the person to tolerate & eventuallymanage the anxiety.
GENERALIZED ANXIETY DISORDER
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GENERALIZED ANXIETY DISORDER
A person with GAD worries excessively and feelshighly anxious at least 50% of the time for 6months or more.
Unable to control this focus on worry, the personhas three or more of the following symptoms:uneasiness, irritability, muscle tension, fatigue,difficulty thinking and sleep alterations.
more people with this chronic disorder are seenby family physicians than by psychiatrists.
Buspirone (buSpar) and SSRI antidepressants arethe most effective treatment.
OS C S SS SO
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POSTTRAUMATIC STRESS DISORDER
PSD can occur in a person who has witnessed anextraordinarily terrifying and potentially deadlyevent.
After the traumatic event, the personexperiences all or some of it through dreams orwaking recollections and responds defensively tothese flash backs.
New behaviors develop related to the trauma,such as sleep difficulties, hyper vigilance,thinking difficulties, severe startle response, andagitation.
ACUTE STRESS DISORDER
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ACUTE STRESS DISORDER
ASD similar to post traumatic stress disorder in
that the person has experienced a traumatic
situation but the response is more dissociative.
the person has a sense that the event was unreal,believes he or she is unreal, and forgets some
aspects of the event through amnesia, emotionaldetachment, and muddled obliviousness to the
environment.