Pre-class Mini Lecture

Mental Health Trauma/Stress(PTSD), Anxiety Disorders, Somatic Symptom

Disorders (BOYD)
We all know that stress is part of our daily lives, but our responses to stress vary from person to
person. For instance, a person may develop a severe emotional reaction (strong agitation of
feelings) and another person is hardly aware of a traumatic event. While most stressful events do
not lead to mental disorders, sometimes, emotional problems and mental disorders develop as the
response to trauma. One reason there is difference between the responses to stress from person to
person, is related to what is known as ___________________. In everyday terms this is described
as the person’s ability to “bounce back” or ability to recover more easily from adversities, illnesses,
like depression. A goal for mental health treatment is to assist the person to gain better coping
strategies that will enhance future ability to be resilient, when faced with adversity.
 Traumatic events include those that are directly experienced, witnessed, learned about from others,
or repeated exposure to adverse events.

Post-Traumatic Stress Disorder (PTSD) is diagnosed following exposure to a traumatic event when
symptoms in four general areas appear:

1) intrusive symptoms, avoidance of person(s), places or objects that are a reminder of the traumatic
event. Intrusive symptoms also include ________________reactions (i.e., feeling or acting as if the
event is re-occurring). Sleeping is difficult. Terrifying ____________s and nightmares often include small
pieces of traumatic events exactly as they happened. Stimuli such as loud noises, and odors, associated
with the trauma cause flashbacks and dreams. Consequently, affected individuals avoid such stimuli.
Many persons diagnosed with PTSD escape situations by altering their state of consciousness or
numbing, by dissociating. Dissociation is a disruption in the normally occurring linkages among
subjective awareness, feelings, thoughts, behavior, and memories.

2) negative mood and cognitions or negative thoughts associated with the event. The person may
become irritable, with episodic explosive anger, guilt, fear and shame, and difficulty feeling love and
happiness. This results in becoming estranged from loved ones, as loved ones do not understand the
changes in person’s behavior.

3) hyperarousal characterized by aggressive, reckless or self-destructive behavior. The traumatized

person is hypervigilant for signs of danger, startles easily, reacts irritably to small annoyances, and
sleeps poorly. The state of hyperarousal causes other problems for family members.

4) sleep disturbances or hypervigilance

***Note: diagnostic criteria (DSM 5) requires that person has experienced these symptoms for at least
1 month

For many, symptoms often develop 3 to 6 months after the event. About a third diagnosed with PTSD
develop chronic symptoms. For these individuals, symptoms fluctuate in intensity with time and usually
are worse during periods of stress. Children with PTSD may react differently than adults.

Examples of Traumatic Events -Military combat violence can result in life-long effects for some
deployed service members, childhood physical abuse, torture, or kidnapping; sexual assault/ rape,
incest; Natural disasters; human disasters; Crime-related events: terror attacks, mugging, witnessing a
murder.

***Note: for a diagnosis of ACUTE STRESS DISORDER- diagnostic criteria (DSM 5) requires that person
has experienced these symptoms for LESS THAN 1 month

Teamwork & Collaboration: Working toward Recovery

Major approaches to the treatment of PTSD include pharmacotherapy and psychotherapy.

Psychotherapeutic approaches to the treatment of patients with PTSD include cognitive behavioral
therapy (CBT); and eye movement, desensitization, and reprocessing (EMDR. Cognitive behavioral
therapies focus on the evaluation of situations, thoughts, feelings and the problematic ways these
evaluations cause a person to act. Group therapy and family therapy are also beneficial to person with
PTSD.

The selective serotonin reuptake inhibitors (SSRIs), benzodiazepines, and β-blockers have been shown to
be effective in reducing the symptoms of PTSD. When prescribed in conjunction with psychotherapy,
pharmacotherapy can minimize the excessive fear and anxiety of PTSD.

Two SSRI antidepressants, sertraline (Zoloft) and paroxetine (Paxil), are approved by the
FDA for PTSD and are used to treat symptoms of sadness, worry, anger and numb feelings.

***Note: Safety Issues!!!: PTSD is associated with an increased risk of __suicide__, suicide attempts,
aggression, and substance abuse. What is the priority intervention?

Anxiety Disorders
The concept of anxiety: Anxiety is an uncomfortable feeling of apprehension which occurs as a result of
internal/external stimuli. Anxiety can result in feelings of dread, and can bring on physical, emotional,
cognitive and behavioral changes. See below breakdown of the levels of anxiety and the associated
symptoms.

Levels of Anxiety: Mild, Moderate, Severe and Panic

Mild-part of everyday living. Perception is sharp, and can see, hear, and grasp more info. You want this
before an exam! Person may be restless, and engage in tension release behaviors like foot tapping.

Moderate-perceptional field narrows, some details lost, grasps less information, has selective
inattention. Problem solving enhanced by having supportive person present. Pounding heart,
perspiration, increased breathing, somatic symptoms like stomach ache or headache, urinary frequency.

Severe-perception drastically reduced, may focus only on one detail, otherwise scattered. Learn and
problem solving not possible. Trembling, nausea, dazed, confused, dizziness. Behavior is automatic in
order to reduce anxiety.

Panic- level-most extreme, markedly disturbed behavior like screaming, shouting, confusion,
withdrawal, hallucinations, delusions, terror, dilated pupils. May dissociate –feel like they are having an
out of body experience.
Defense Mechanisms

We all use defense mechanisms to reduce anxiety. We do this by preventing or limiting unwanted
thoughts and feelings. See Chapter in text for definitions. While defense mechanisms can be useful in
coping with everyday problems, they also can become problematic when overused.

Clinical application: When a nurse is working with a client, the first step is
identifying a person’s use of defense mechanisms. The next step is determining whether the reasons the
defense mechanisms are being used support healthy coping or are detrimental to a person’s health.
What may be healthy for one person may be unhealthy for another. (see Defense Mechanisms Handout
in Canvas module)

Anxiety and Co-Morbidities-

Highly co-occurring with substance abuse and major depressive disorder (MDD)

Frequently co-occurring with eating disorder, bipolar disorder, persistant depressive disorder

Co-occurring medical conditions cancer, heart disease, hypertension, irritable bowel syndrome, renal
or liver dysfunction, reduced immunity

Chronic anxiety associated with increased risk for cardiovascular morbidity and mortality

Neurobiology, Limbic system, Serotonin, norepinephrine, gamma-aminobutyric acid (GABA)

Panic Disorders

Panic attack: Sudden onset of extreme apprehension or fear, usually with a feeling of doom, Terror is so
severe that normal function is suspended. Signs similar to a_____________.

Phobias-Persistent, intense irrational fear of something, Social anxiety disorders (SADs) or social phobias
(e.g., agoraphobia)

General Anxiety Disorders (GAD)- Excessive worry and anxiety for at least 6 months and is general in
nature. Severe distress with pervasive cognitive dysfunction and impaired functioning; no specific
triggers or targets. The patient with GAD may report being a chronic worrier, and worry about
everything from job, finances, health of family members, and many cannot remember a time when they
weren’t anxious.

The treatment is the similar to the care for panic disorder. Medications

Psychoeducation Checklist for GAD:

 Psychopharmacologic agents (benozs, antidepressants, non-benzo

antidepressants and beta blockers)

 Relaxation strategies like breathing control and progress muscle

relaxation.

 Positive coping strategies, nutrition and diet restrictions

 Sleep measures and time management
Agoraphobia- is fear or anxiety triggered by about two or more situations such as using public
transportation, being in open spaces, being in enclosed places, standing in line, being in a crowd, or
being outside of the home alone (APA, 2013). When these situations occur, the individual believes
that something terrible might happen and that escape may be difficult. The individual may
experience panic-like symptoms or other embarrassing symptoms (e.g., vomiting, diarrhea) (APA,
2013). Agoraphobia leads to avoidance behaviors. Such avoidance interferes with routine
functioning and eventually renders the person afraid to leave the safety of home.

Specific Phobia- objects or situations include dogs, spiders, heights, storms, water, blood, and closed
spaces, among others. Specific common, but do not usually cause much difficulty.

Social Anxiety Disorders

Social Phobias—SAD Is severe anxiety provoked by exposure to a social or performance situation. Fear
of saying something foolish, not being able to answer questions in a classroom, eating in the presence of
others, and performing on a stage, among others Fear of public speaking is the most common.

Obsessive-Compulsive Disorder
Obsessions: Unwanted, intrusive, persistent ideas, thoughts, impulses, or images that cause significant
anxiety or distress.

Compulsions: Unwanted, ritualistic behavior the individual feels driven to perform to reduce anxiety

-“Normal” individuals may experience mild obsessive-compulsive behaviors. Mild compulsions are
valued traits in U.S. society.

-More severe symptoms: Center on dirtiness, contamination, and germs and occur with corresponding
compulsions such as cleaning and hand washing

-Most severe symptoms: Include persistent thoughts of sexuality, violence, illness, and death.

Nursing Interventions

The importance of establishing a therapeutic relationship with a person with OCD cannot be emphasized
enough! This requires patience and active listening. The individual may go to great lengths to explain
some minute aspect of her or his life. It is important not to interrupt or rush these explanations. Being
unable to finish thoughts increases the patient’s anxiety and frustration.

The nurse’s interpersonal skills are crucial to successful intervention with the patient who has OCD.
Nurses must control their own anxiety. The nurse should interact with the individual in a calm, non-
authoritarian fashion without exhibiting any disapproval of the patient or the patient’s behaviors while
demonstrating empathy about the distress that the disorder has caused. This approach is one of the
most effective means available for communicating appreciation for the individual as separate from the
illness.
Medications Selective serotonin reuptake inhibitors (SSRIs), including
_Fluoxetine____,_Fluvoxamine______,__paroxetine_____,_Sertraline____are recommended
medications. Clomipramine (a tricyclic antidepressant) is also frequently prescribed and was the first
drug to produce significant advances in treating OCD (U.S. Department of Health and Human
Services [HHS], 2012).
Non-pharmacological Interventions:
Exposure and Response Prevention The patient is exposed to situations or objects that are
known to cause anxiety, only they are asked not to respond with ritualistic behaviors.
Thought stopping- The person is taught to interrupt obsessional thoughts by saying, “Stop!” either
aloud or silently.
Cognitive Restructuring-The patient is taught to monitor automatic thoughts and then to recognize
the connection between thoughts, emotional response, and behaviors. The distorted thoughts are
examined and tested by for-or-against evidence presented by the therapist, which helps the
individual to realistically assess the likelihood that the feared event will happen if the compulsive
behavior is not performed.
Relaxation to help reduce anxiety and Cue Cards that contain positive statements are also tools
taught to the patient to reduce anxiety.

KEY interventions for a hospitalized patient include:

 For a hospitalized individual, unit routines must be carefully and clearly explained to
decrease fear of the unknown. Initially, do not prevent the individual from engaging in
rituals because the person’s anxiety level will increase. Recognize the significance of the
rituals to the person and empathize with the person’s need to perform them. Assist the
individual in arranging a schedule of activities that incorporates some private time but
also integrates the person into normal unit activities.
IMPORTANT! Concept to Understand -the goal is to reduce the amount of time the patient
engages in the ritualistic behavior (compulsion), but that even with therapy, the patient may still
have lingering rituals they must perform, just lessened in time doing so.
Other related OCD disorders include:
Body Dysmorphic Disorder involves excessive focus on slight or imagined defects in
appearance. The person with these extremely distressing defects seeks treatment by plastic
surgeons or dermatologists. Correction does not relieve the patient’s preoccupation, which
continues to interfere with his or her quality of life. These individuals are high risk for depression
and suicide.
Hoarding disorder can begin in childhood and last a lifetime. Individuals with this disorder need
to save things and become very upset if items are removed. When excessive collection leads to
extreme clutter, it becomes a safety issue.

Somatic Symptom Disorders (SSD) is a chronic relapsing condition characterized by

multiple physical symptoms of unknown origin that develop during times of emotional
distress.
 Nurses in primary care and medical–surgical settings are more likely than mental
health nurses to encounter persons with these problems.
 Terms associated with SSD: La belle indifference-patient’s lack of concern over
physical illness ex. -“by the way, do you know I am blind?” seen in conversion
 disorder. Primary gain-reduced anxiety resulting from being able to deal with a
stressful situation. Secondary gain-rewards patient gets from being in the “sick
role”, ex.-sympathy from others, getting out of chores.
 Persons with SSD tend to “provider shop,” moving from one to another until they
find one who will give them new medication, hospitalize them, or perform
surgery.
 **NOTE: the source of worrisome physical symptoms cannot be
determined through medical or laboratory tests, medical or psychiatric
interviews, or medical imaging,
 The most common characteristics are:
* Reporting the same symptoms repeatedly
*Receiving support from the environment that otherwise might not be forthcoming
(e.g., gaining a spouse’s attention because of severe back pain)
*Expressing concern about the physical problems inconsistent with the severity
of the illness (being “sicker than the sick”)
 Note: Symptoms are not voluntarily controlled or created

Other Related Disorders:

Illness Anxiety Disorder (formerly hypochondrias)- fearful about developing a serious illness
based on their misinterpretation of body sensations. The fear of having an illness continues
despite medical reassurance and interferes with psychosocial functioning. They spend time and
money on repeated examinations looking for feared illnesses.
Conversion Disorder-have neurologic symptoms that include impaired coordination or balance,
paralysis, difficulty swallowing or a sensation of a lump in the throat; also may have loss of
touch, vision problems, blindness, deafness, and hallucinations. In some instances, they may
have seizures. The laboratory, electroencephalographic, and neurologic test results are typically
negative.
Interventions
Development of a Therapeutic Relationship. Therapeutic communication techniques should be used to
refocus the patient on psychosocial problems related to the physical manifestations

NOTE: Reduction of Patient Anxiety About Illness is another goal of treatment!

Physical Health Interventions Nursing interventions that focus on physical health become especially
important because medical treatment must be conservative; aggressive pharmacologic treatment
must be avoided. Each time a nurse sees the patient, a limited time should be spent respectfully
discussing physical complaints. During the discussion, to the nurse must project the belief that the
patient is truly experiencing these problems
Medications Interventions- No medication is specifically recommended for patients with SSD;
however, psychiatric symptoms of comorbid disorders, such as depression and anxiety, should be
treated pharmacologically as appropriate. Phenelzine (Nardil) is one of the monoamine oxidase
inhibitors (MAOIs) that are effective in treating not just depression but also the chronic pain and
headaches common in people with SSD. Food–drug interactions are the most serious side effects of
MAOI

FACTITIOUS DISORDERS Persons with factitious disorders intentionally cause an illness or

injury to receive the attention of health care workers. These individuals are motivated solely by
the desire to become a patient and develop a dependent relationship with a health care
provider. Factitious disorders are Conscious and Voluntary!

 Two types of factitious disorders: factitious disorder (Münchausen’s) and factitious

disorder imposed on another (Münchausen’s by proxy) .

 Fabricating a physical illness, having recurrent hospitalizations, and going from one
health care provider to another

 differentiated from malingering, in which the individual who intentionally produces

symptoms of illness and is is motivated by another specific self-serving goal, such as
being classified as disabled or avoiding work.
Comparison of Somatic Symptom Disorders vs. Dissociative Disorders

 Somatic Symptom Disorders Characterized by the presence of multiple, real, and/or physical
symptoms for which no evidence of medical illness is revealed. Accompanied by abnormal
thoughts, feelings and reactions to these symptoms

 Dissociative Disorders Characterized by mental detachment from conscious awareness in

reaction to abuse. Involve a disruption in the consciousness with a significant impairment in
memory, identity, social functioning, or perceptions of self.

 Dissociative Disorders Hallmark Characteristics-Disturbances in a normally well-integrated

continuum of consciousness, memory, identity, and perception.

 **Note: Dissociation—is the unconscious ________________to protect an individual against

overwhelming anxiety.

 Depersonalization/Derealization Disorder-Recurrent periods of feeling unreal, detached,

outside the body, dreamlike, numb, or with a distorted sense of time or visual perception.-
Reality testing remains intact. Symptoms are not related to medical condition or substance use

 Dissociative Amnesia-Psychologically induced memory loss and inability to recall important

personal information after severe stressor

Nursing Plan and interventions for dissociative disorders would include the following:

 Reduce environmental stimuli

 Stay with patient during times of depersonalization as they will be fearful

 Document observation of different separate personalities

 Ensure safety and institute suicide precautions If needed

 NOTE: goal of therapy is to assist patient to develop new coping strategies to prevent
dissociation in the future!