Mental health & crisis management 7 APRIL qui z

Jack Fowler

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Stress, coping and Anxiety

Stress

Severe stress is unhealthy and can weaken biological resistance to psychiatric pathology in any individual

Stress is especially harmful for those who have a genetic predisposition to mental illness/mental disorders

While an understanding of the connection between stress and mental illness is essential in the psychiatric setting, it is also important when developing a plan of care for any patient, in any setting, with any diagnosis

 Imagine having an appendectomy and being served with an eviction notice on the same day - How well could you cope with either situation, let alone both simultaneously?

The nurse's role is to intervene to reduce stress by promoting a healing environment, facilitating successful coping, and developing future coping strategies

Source: Halter, M. J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A clinical approach (2nd edition). Elsevier.

Stress Response – Lazarus (2012)

The body responds the same physiologically regardless of whether the stress is real or only perceived as a threat and whether the threat is physical, psychological, or social

Lazarus (2012) describes these reactions as distress and eustress:

Distress is a negative, draining energy that results in anxiety, depression, confusion, helplessness, hopelessness, and fatigue

Distress may be caused by such stressors as a death in the family, financial overload, or school or work demands

Eustress is a positive, beneficial energy that motivates and results in feelings of happiness, hopefulness, and purposeful movement

Eustress may be the result of a much-needed vacation, being called in for an interview, the birth of a baby, or buying a new car

Eustress could lead to a depletion of physiological resources if sustained

Source: Halter, M. J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A clinical approach (2nd edition). Elsevier.

SOME REACTIONS TO ACUTE AND PROLONGED (CHRONIC) STRESS
ACUTE STRESS CAN CAUSE	PROLONGED (CHRONIC) STRESS CAN CAUSE
Uneasiness and concern	Anxiety and panic attacks
Sadness	Depression or melancholia
Loss of appetite	Anorexia or overeating
Suppression of the immune system	Lowered resistance to infections, leading to an increase in opportunistic viral and bacterial infections
Increased metabolism and use of body fats	Insulin-resistant diabetes
	Hypertension
Infertility	Amenorrhea or loss of sex drive
	Impotence, anovulation
Increased energy mobilization and use	Increased fatigue and irritability
	Decreased memory and learning
Increased cardiovascular tone	Increased risk for cardiac events (e.g., heart attack, angina, and sudden heart-related death)
	Increased risk for blood clots and stroke
Increased cardiopulmonary tone	Increased respiratory problems

Source: Halter, M. J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A clinical approach (2nd edition). Elsevier.

Neurotransmitters involved in the stress response

Serotonin is a brain catecholamine that plays an important role in mood, sleep, sexuality, appetite, and metabolism

One of the main neurotransmitters implicated in depression

During times of stress, serotonin synthesis becomes more active

This stress-activated turnover of serotonin is at least partially mediated by the corticosteroids, and researchers believe this activation may dysregulate (impair) serotonin receptor sites and the brain's ability to use serotonin

Source: Halter, M. J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A clinical approach (2nd edition). Elsevier.

Assessing Coping Styles

People cope with life stressors in a variety of ways, and a number of factors can act as effective mediators to decrease stress in our lives.

Rahe (1995) identified four discrete personal attributes (coping styles) people can develop to help manage stress:

1. Health-sustaining habits (e.g., medical compliance, proper diet, relaxation, adequate rest and sleep, pacing one's energy)

2. Life satisfactions (e.g., occasional escapism, reading, movie watching, work, family, hobbies, humour, spiritual solace, arts, nature)

3. Social supports (e.g., talk with trusted friends, family, counsellors, or support groups)

4. Effective and healthy responses to stress (e.g., work off anger through physical activity, go for a walk, dig in the garden, do yoga)

Source: Halter, M. J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A clinical approach (2nd edition). Elsevier.

POSITIVE AND NEGATIVE RESPONSES TO STRESS

POSITIVE AND NEGATIVE RESPONSES TO STRESS
POSITIVE STRESS RESPONSES	NEGATIVE STRESS RESPONSES
Problem solving—figuring out how to deal with the situation	Avoidance—choosing not to deal with the situation, letting negative feelings and situations fester and continue to become chronic
Using social support—calling in others who are caring and may be helpful	Self-blame—faulting oneself, which keeps the focus on minimizing one's self-esteem and prevents positive action toward resolution or working through the feelings related to the event
Reframing—redefining the situation to see both positive and negative sides, as well as the way to use the situation to one's advantage	Wishful thinking—believing that things will resolve themselves and that “everything will be fine” (a form of denial)

Source: Halter, M. J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A clinical approach (2nd edition). Elsevier.

Anxiety and Anxiety Disorders

Anxiety

Anxiety is a universal human experience and is the most basic of emotions

Defined as a feeling of apprehension, uneasiness, uncertainty, or dread resulting from a real or perceived threat

Normal anxiety is a healthy reaction necessary for survival

Provides us with energy to carry out everyday tasks and strive toward goals; motivates us to make and survive change; and prompts constructive behaviours, such as studying for an examination, being on time for a job interview, preparing for a presentation, and working toward a promotion

The common element of anxiety disorders is that those affected experience a degree of anxiety so high that it interferes with personal, occupational, or social functioning

All anxiety-related disorders tend to be persistent and are often disabling

Source: Halter, M. J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A clinical approach (2nd edition). Elsevier.

Source: Austin, W. & Boyd, M.A. (2015). Psychiatric & mental health nursing (3rd ed.). Philadelphia, PA: Wolters Kluwer.

Levels of anxiety

Mild Anxiety

Occurs in the normal experience of everyday living, allows an individual to perceive reality in sharp focus

A person experiencing a mild level of anxiety sees, hears, and grasps more information

Physical symptoms may include slight discomfort, restlessness, irritability, or mild tension-relieving behaviours (e.g., nail biting, foot or finger tapping, fidgeting, wringing of hands)

Moderate Anxiety

As anxiety increases, the perceptual field narrows, and some details are excluded from observation

The person experiencing moderate anxiety sees, hears, and grasps less information and may demonstrate selective inattention, in which only certain things in the environment are seen or heard unless they are pointed out

Physical symptoms of moderate anxiety include tension, pounding heart, increased pulse and respiratory rate, perspiration, and mild somatic symptoms (gastric discomfort, headache, urinary urgency)

Source: Halter, M. J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A clinical approach (2nd edition). Elsevier.

Levels of anxiety

Severe Anxiety

The perceptual field of a person experiencing severe anxiety is greatly reduced

A person with severe anxiety may focus on one particular detail or many scattered details and have difficulty noticing his or her environment, even when it is pointed out by another

Learning and problem solving are not possible at this level, and the person may seem confused

Behaviour becomes automatic (e.g., wringing hands, pacing) and is aimed at reducing or relieving anxiety

Somatic symptoms such as headache, nausea, dizziness, and insomnia often increase; trembling and a pounding heart are common; and the person may hyperventilate and experience a sense of impending doom or dread

Source: Halter, M. J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A clinical approach (2nd edition). Elsevier.

Neurotransmitters involved in anxiety

Norepinephrine

Implicated in anxiety disorders because of its effects on the systems associated with the physical sensations of anxiety—the cardiovascular, respiratory, and gastrointestinal systems via stimulation of the sympathetic arm of the autonomic nervous system

Serotonin [5-hydroxytryptamine (5-HT)]

Indirectly implicated in the aetiology of anxiety disorders in that drugs that facilitate serotonergic neurotransmission are effective in treating anxiety and panic symptoms

Selective serotonin reuptake inhibitors (SSRIs) and selective serotonin and norepinephrine reuptake inhibitors (SNRIs) are efficacious treatments

Panic

The most extreme level of anxiety

Results in noticeably disturbed behavior

Someone in a state of panic is unable to process what is going on in the environment and may lose touch with reality, even experiencing hallucinations, or false sensory perceptions (e.g., seeing people or objects not really there)

Physical manifestations may include pacing, running, shouting, screaming, or withdrawal, and actions may become erratic, uncoordinated, and impulsive

These sorts of automatic behaviours are used to reduce or relieve anxiety, although such efforts may be ineffective

Acute panic may lead to exhaustion

Source: Halter, M. J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A clinical approach (2nd edition). Elsevier.

Source: Austin, W. & Boyd, M.A. (2015). Psychiatric & mental health nursing (3rd ed.). Philadelphia, PA: Wolters Kluwer.

Clinical picture

Anxiety exerts a powerful influence on the mind and body. The experience of anxiety is an underlying factor in several disorders, including:

Acute stress disorder

Anxiety disorder not otherwise specified

Anxiety due to medical conditions

Depersonalization/derealization disorder

Generalized anxiety disorder

Obsessive-compulsive disorder and related disorders

Panic disorders

Phobias

Post-traumatic stress disorder

Somatic symptom disorder

Substance-induced anxiety disorder

Source: Halter, M. J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A clinical approach (2nd edition). Elsevier.

GENERIC CARE PLAN FOR GENERALIZED ANXIETY DISORDER
Nursing diagnosis: Ineffective coping related to persistent anxiety as evidenced by fatigue and irritability. Outcome: Patient will maintain role performance.
SHORT-TERM GOAL	INTERVENTION	RATIONALE
1. Patient will state that immediate distress is decreased by end of session.	1a. Stay with patient.	1a. Conveys acceptance and ability to give help
	1b. Speak slowly and calmly.	1b. Conveys calm and promotes security
	1c. Use short, simple sentences.	1c. Promotes comprehension
	1d. Assure patient that you are in control and can assist him or her.	1d. Counters feeling of loss of control that accompanies severe anxiety
	1e. Give brief directions.	1e. Reduces indecision; conveys belief that patient can respond in a healthy manner
	1f. Decrease excessive stimuli; provide quiet environment.	1f. Reduces need to focus on diverse stimuli; promotes ability to concentrate
	1g. After assessing level of anxiety, administer appropriate dose of anxiolytic agent if warranted.	1g. Reduces anxiety and allows patient to use coping skills
2. Patient will be able to identify source of anxiety by (date).	2a. Encourage patient to discuss preceding events.	2a. Promotes future change through identification of stressors
	2b. Link patient's behaviour to feelings.	2b. Promotes self-awareness
	2c. Teach cognitive therapy principles: • Anxiety is the result of a dysfunctional appraisal of a situation. • Anxiety is the result of automatic thinking.	2c. Provides a basis for behavioural change
	2d. Ask questions that clarify and dispute illogical thinking	2d. Helps promote accurate cognition
	2e. Have patient give an alternative interpretation.	2e. Broadens perspective; helps patient think in a new way about problem or symptom
3. Patient will identify strengths and coping skills by (date).	3a. Have patient identify what has provided relief in the past.	3a. Provides awareness of self as individual with some ability to cope
	3b. Have patient write assessment of strengths.	3b. Increases self-acceptance
	3c. Reframe situation in ways that are positive.	3c. Provides a new perspective and converts distorted thinking

Source: Halter, M. J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A clinical approach (2nd edition). Elsevier.

Putting together – stress and anxiety

Source: Halter, M. J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A clinical approach (2nd edition). Elsevier.

Obsessive Compulsive Disorder

Neuroses are characterized by anxiety, depression, or other feelings of unhappiness or distress that are out of proportion to the circumstances of a person's life.

Includes Diseases: Obsessive–compulsive disorder

Obsessive-Compulsive Disorder (OCD)

Severe obsessions or compulsions that interfere with life

Obsessions:

Unwanted thoughts, intrusive

Persistent thoughts, impulses, or images that cause anxiety and distress

Fear of contamination

Compulsions:

Repetitive behaviours performed in a ritualistic way that relieve anxiety

Source: Austin, W. & Boyd, M.A. (2015). Psychiatric & mental health nursing (3rd ed.). Philadelphia, PA: Wolters Kluwer.

OCD

Obsessions create anxiety, and compulsions are performed to reduce anxiety

Common compulsions:

Washing, cleaning, checking, counting, repeating actions

Ordering, making confessions, and requesting assurances

If sequence is disturbed, person experiences anxiety

Most common obsessions:

Fear of contamination, resulting compulsion toward hand washing

Dissociation: a breakdown in integrated functions of memory, consciousness, perception of self, environment, or sensory and motor behaviour

Depersonalization: loss of sense of personality

Coexists with Tourette’s syndrome

Source: Austin, W. & Boyd, M.A. (2015). Psychiatric & mental health nursing (3rd ed.). Philadelphia, PA: Wolters Kluwer.

COMMON OBSESSIONS AND COMPULSIONS
TYPE OF OBSESSION	EXAMPLE	ACCOMPANYING COMPULSION
Losing control	Fear of acting on an impulse to harm oneself	Praying to prevent harm to oneself
Harm	Fear of being responsible for something terrible happening	Checking that nothing terrible happened Checking that you did not make a mistake
Perfectionism	Need for symmetry—concern about evenness Inability to decide whether to keep or discard things	Rereading or rewriting Putting things in order or arranging things until it “feels right” Collecting items that results in significant clutter in the home (hoarding)
Contamination	Environmental contaminants (radiation, oil, or lead) Germs or viruses	Cleaning household items in a certain way to remove contaminants Washing hands excessively
Religious obsessions	Concern with offending God Excessive concern with morality	Praying to seek forgiveness Repeatedly touching or kissing religious objects Replaying interactions with others and repeatedly reviewing every remark to determine if you said anything wrong
Other obsessions	Concern about getting a disease, such as cancer, colitis, or diabetes	Checking some parts of your physical condition or body
	Superstitious ideas	Repeating activities in “multiples” (e.g., doing a task three times because three is a “good,” “right,” or “safe” number)

Source: Halter, M. J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A clinical approach (2nd edition). Elsevier.

Lisa-Marie Woodley (LW) -

Nursing Management: Biologic Domain

Source: Austin, W. & Boyd, M.A. (2015). Psychiatric & mental health nursing (3rd ed.). Philadelphia, PA: Wolters Kluwer.

Assessment for multiple physical symptoms

Physical fears

Physical consequences of compulsions

Nutrition and sleep status

Dermatologic lesions secondary to hand washing

Nursing Management: Psychological Assessment

Source: Austin, W. & Boyd, M.A. (2015). Psychiatric & mental health nursing (3rd ed.). Philadelphia, PA: Wolters Kluwer.

Type and severity of obsessions and compulsions

Degree to which the OCD symptoms interfere with patient’s daily functioning

Consider using rating scales

Suicide assessment

Psychological Interventions

Source: Austin, W. & Boyd, M.A. (2015). Psychiatric & mental health nursing (3rd ed.). Philadelphia, PA: Wolters Kluwer.

Response prevention

Thought stopping

Relaxation techniques

Cognitive restructuring

Cue cards

Psychoeducation

Nursing Management: Social Domain

Source: Austin, W. & Boyd, M.A. (2015). Psychiatric & mental health nursing (3rd ed.). Philadelphia, PA: Wolters Kluwer.

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

Other Anxiety Disorders

Source: Austin, W. & Boyd, M.A. (2015). Psychiatric & mental health nursing (3rd ed.). Philadelphia, PA: Wolters Kluwer.

Specific phobia

General Anxiety Disorder

Social phobia

Acute stress disorder