Crisis & Crisis

Interventions
LOURADEL ULBATA- ALFONSO, MAN, RN

CRISIS
a situation or period in an individuals life that
produces an overwhelming emotional response.
This event occurs when an individual is confronted by
a certain life circumstance or stressor that he or she
cannot effectively manage by using his or her usual
coping skills.
Crisis is an unexpected event that can create
uncertainty to an individual and has been viewed as a
threat to a persons important goals

CRISIS

CRISIS

CRISIS

(Stages)

1) The person is exposed to a stressor, experience

anxiety, and tries to cope in a customary fashion.

CRISIS

CRISIS

(Stages)

2) Anxiety increases when customary coping skills are

ineffective.

CRISIS

CRISIS

(Stages)

3) The person makes all possible efforts to deal with the

stressors, including attempts at new methods of
coping.

CRISIS

CRISIS

(Stages)

4) When coping attempts fail, the person experiences

disequilibrium and significant distress.

CRISIS

CRISIS

(CATEGORIES- maturational

crises)
1) Sometimes called developmental crises, are
predictable events in the normal course of life, such as
leaving home for the first time, getting married,
having a baby, and beginning a career.

CRISIS

CRISIS

(CATEGORIES- situational

crises)
2) Unanticipated or sudden events that threaten the
individuals integrity, such as death of loved one, loss
of a job, and physical or emotional illness in the
individual or family member.

CRISIS

CRISIS

(CATEGORIES- adventitious

crises)
3) Also called social crises which include natural disaster
like floods, earthquakes, or hurricanes; war; terrorist
attacks; riots; and violent crimes such as rape or
murder.

CRISIS

Characteristics of a Crisis state

Highly individualized
Lasts for 4-6 weeks
Self-limiting
Person affected becomes passive and submissive
Affects a persons support system

PHASES OF A CRISIS
Pre-crisis: State of equilibrium
Initial Impact (may last a few hours to a few days):
High level of stress, helplessness, inability to function
socially
Crisis (may last a brief or prolonged period of time):
Inability to cope, projection, denial, rationalization
Resolution: attempts to use problem-solving skills
Post crisis: may have OLOF or may have symptoms of
neurosis, psychosis

CRISIS INTERVENTION

CRISIS INTERVENTION
refers to the methods used to offer immediate, shortterm help to individuals who experience an event that
produces emotional, mental, physical, and behavioral
distress or problems.
Role of the nurse is to return the client to its pre-crisis
state by assisting and guiding them until they achieved
their OLOF.
Goal: to enable patient to attain an OLOF
Nurses Primary Role: Active and Directive

CRISIS

(intervention)

1) Supportive Interventions
Aim at dealing with the persons needs for empathetic
understanding, such as encouraging the person to
identify and discuss feelings, serving as sounding
board for the person, and affirming the person's selfworth.
CRISIS

CRISIS

(intervention)

1) Directive Interventions
Designed to assess the persons health status and
promote problem-solving, such as offering the person
new information, knowledge, or meaning; raising the
persons self-awareness by providing feedback about
behaviour; and directing the persons behaviour by
offering suggestions or courses of actions.

CRISIS

Steps in Crisis Intervention

Identify the degree of disruption the client is
experiencing
Assess the clients perception of the event
Formulate nursing diagnoses
Involve the patient and family if applicable with
planning
Implement interventions- new and old coping
mechanisms
Evaluate-reassessment, reinforcement

Guide for an effective crisis

intervention:
Assist the person to view the event or issue in a
different perspective.
Assist the individual to use the existing support
systems. It is vital to help the person find new sources
of support that can help in decreasing the feelings of
being alone or overwhelmed.
Assist the individual in learning new methods of coping
that will help resolve the current crisis and give him or
her new coping skills to be used in the future when
dealing with another overwhelming situation.

ANXIETY DISORDERS

ANXIETY
Vague, subjective non specific feeling.
*uneasiness, apprehension
*tension,feeling of dread or impending doom
it is a response to external or internal stimuli that can
have behavioral, emotional, cognitive, and physical
symptoms.
Causes- result of threat to ones Biologic, Physiologic
and Social Integrity- external influences

FEAR
Is feeling afraid or threatened by a clearly
identifiable external stimulus that
represents danger to the person

Anxiety Disorder
Demonstrates unusual behavior and
are experiencing significant distress
overtime which significantly impairs
their daily routines, social lives, and
occupational functioning.

Concept of Anxiety

Anxiety Disorders
Panic without
reason!!
Unwarranted
fear!!! Objects
life conditions
Uncontrollable repetitive
actions!!!

Reexperience of traumatic
events!!!
Unexplainable or
overwehelming worry!!!

Concept of Anxiety

Stress
is the wear and tear that life causes on the
body
It occurs when a person has difficulty
dealing with life situations, problems, and
goals

General Adaptation Syndrome

Hans Selye (1956, 1974), an endocrinologist, identified
the physiologic aspects of stress
He determined three stages of reaction to stress

STAGES

ALARM STAGE
which provides a burst of energy.
During the 'alarm stage' the body
responds to the distress signal sent to
the hypothalamus with a burst of energy
to help deal with the stressor.
E.g. release of adrenaline and
norepinephrine
Activation of sympathetic nervous system

Resistance Stage
the body attempts to resist or adapt to the stressor
the body will continue to maintain a level or alertness
to help fight or adapt to the stressor.
Deep energy reserves are used until the stressor is
resolved or reserves are depleted.
Because the body's energies are going to the stressor,
the body is not able to fight off colds and flu during this
time

Exhaustion Stage
Energy is depleted
occurs when the person has 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.

LEVELS OF ANXIETY

Levels of Anxiety (Mild Anxiety)

Sensation that something
is different and warrants
special attention. Sensory
stimulation increases and
helps the person focus
attention to learn, solve
problems, think, act, feel,
and protect himself or
herself.
Concept of Anxiety

Levels of Anxiety (Moderate Anxiety)

A disturbing feeling that
something is definitely wrong;
the person becomes nervous
or agitated.
Can still process information,
solve problems, learn new
things with assistance from
others.
Person has difficulty
concentrating independently
but can be redirected to the
topic.
Concept of Anxiety

Levels of Anxiety (Severe Anxiety)

Person has trouble thinking
and reasoning. Muscles
tighten, and vital signs
increase.
Restless, irritable, and angry;
or uses similar emotional
psychomotor means to release
tension.

Concept of Anxiety

Levels of Anxiety (Panic Anxiety)

Emotional-psychomotor realm
predominates with
accompanying fight, flight, or
freeze responses, adrenaline
surge greatly increases vial
signs.
Pupils enlarge to let in more
light, and the only cognitive
process focuses on the
persons defence.
Concept of Anxiety

Levels of Anxiety (MANIFESTATIONS)

MILD ANXIETY
PSYCHOLOGICAL RESPONSE

PHYSIOLOGIC RESPONSE

Wide perceptual field

Restlessness

Sharpened senses

Fidgeting

Increased motivation

GI butterflies

Effective problem-solving

Difficulty Sleeping

Increased learning ability

Hypersensitive to noise

Concept of Anxiety

Levels of Anxiety (MANIFESTATIONS)

MODERATE ANXIETY
PSYCHOLOGICAL RESPONSE
Perceptual field narrowed to
immediate task

PHYSIOLOGIC RESPONSE
Muscle tension
Diaphoresis

Selectively attentive

Pounding pulse

Can not connect thoughts or

Headache

events independently
Increased use of automatisms

Dry mouth
High voice pitch
Faster rate of speech
GI upset

Concept of Anxiety

Frequent urination

Levels of Anxiety (MANIFESTATIONS)

SEVERE ANXIETY
PSYCHOLOGICAL RESPONSE

PHYSIOLOGIC RESPONSE

Perceptual field reduced to one

detail scattered details.
Cannot complete tasks
Cannot solve problems or learn
effectively
Behaviour geared toward
anxiety relief and is usually
ineffective.
Doesnt respond to redirection
Feels awe, dread, or horror
Cries
Ritualistic Behaviour

Severe headache
Nausea, vomiting, and diarrhea
Trembling
Rigid stance
Vertigo
Pale
Tachycardia
Chest pain

Concept of Anxiety

Levels of Anxiety (MANIFESTATIONS)

PANIC ANXIETY
PSYCHOLOGICAL RESPONSE
Perceptual field reduced to
focus on self
Cannot process any
environmental stimuli
Distorted perceptions
Loss of rational thought
Doesnt recognize potential
danger
Cant communicate verbally
Possible delusions and
hallucinations
May be suicidal

Concept of Anxiety

PHYSIOLOGIC RESPONSE
May bolt and run
Totally immobile and mute
Dilated pupils
Increased blood pressure and
pulse
Fight, flight, or freeze

Interventions for Severe and Panic

Levels of Anxiety

Maintain a calm manner.

Remain with the person.
Minimize environmental stimuli.
Reinforce reality.
Listen for themes in communication.
Attend to physical safety and medical needs first.
Physical limits may need to be set.
Provide opportunities for exercising.
Assess the persons need for medication or seclusion.

Etiological Theories of
Anxiety

Etiological Theories of Anxiety

Biologic Model
Hans Selye- expanded the idea that endocrine system and
CNS (hypothalamus and Pituitary gland ) have reciprocal
relationships
Studies of the neuropharmacology of the Autonomic Nervous
System (ANS) re: regulation of Cardiovascular/GI/Motor
systems was shown responsive to stimuli
RXs target serotonin, noradrenergic,& y-amino-butyric
acid(GABA)

Psychodynamic Model
Concept views Anxiety as a warning to the ego
Three types Anxiety identified
REALITY Anxiety(painful emotional experience resulting
from perception of danger in external world)
MORAL Anxiety (THE Egos experience of Guilt and Shame)
NEUROTIC Anxiety (perception of threat according to ones
instincts)
Neurotic sxs develop to defend against anxiety

Interpersonal /Social Psychology

Models/Anxiety
Anxiety is the response to external environment
Sullivan:Anxiety is the first great educative experience
in living
Symptoms were response to
expectations/insecurities/frustrations/conflicts between
person and Primary Groups i.e..family, colleagues, social
associates.
Emphasis on early development

Behavioral Model/Anxiety
Based on Learning theory- etiology of sxs based
on generalization of an earlier traumatic
experience to a benign setting or object.
Links past experiences with present responses
anxiety occurs when a signal predicts a painful or
feared event
May be linked to PTSD

DEFENSE MECHANISM

DEFENSE MECHANISM
describe the unconscious attempt to obtain relief from
emotional conflict or anxiety.
a coping technique that reduces anxiety arising from
unacceptable or potentially harmful impulses.

DEFENSE MECHANISM
Purposes:
1. To resolve a mental conflict.
2. To reduce anxiety or fear
3. Protect ones self-esteem
4. Protect ones sense of security

 Four Levels of Defense

The psychiatrist George Eman Vaillant introduced a four-level
classification of defence mechanisms:
Level I - pathological defences (psychotic denial, delusional
projection)
Level II - immature defences (fantasy, projection, passive
aggression, acting out)
Level III - neurotic defences (intellectualization, reaction
formation, dissociation, displacement, repression)
Level IV - mature defences (humour, sublimation,
suppression, altruism, anticipation)

Level 1: Pathological
The mechanisms on this level, when predominating,
almost always are severely pathological.
These permit one to effectively rearrange external
experiences to eliminate the need to cope with reality.
The pathological users of these mechanisms frequently
appear irrational or insane to others.
These are the "psychotic" defences, common in overt
psychosis. However, they are normally found in dreams
and throughout childhood as well.

Level 1: Pathological
Conversion: -The transferring of mental conflict into a physical symptom to
release tension or anxiety.
Ex: an elderly woman experiences sudden blindness after witnessing a
robbery
Ex: a middle-aged man develops paralysis of his lower extremities
after he learns that his wife has terminal cancer
Denial: The unconscious refusal to face thoughts, feelings, wishes, needs, or
reality factors that are intolerable. Also defined as blocking the awareness of
reality by refusing to acknowledge its existence.
Ex: A person who is told he has terminal cancer denies the diagnosis
by telling his family he had a little tumor on his lung and his doctor
removed all of it.
Distortion: A gross reshaping of external reality to meet internal needs.

Level 2: Immature
These mechanisms are often present in adults.
These mechanisms lessen distress and anxiety
produced by threatening people or by an
uncomfortable reality.
Excessive use of such defences is seen as socially
undesirable, in that they are immature, difficult
to deal with and seriously out of touch with
reality.
These are the so-called "immature" defences and
overuse almost always leads to serious problems
in a person's ability to cope effectively.
These defences are often seen in major

Level 2: Immature
Acting out: Direct expression of an unconscious wish or impulse in
action, without conscious awareness of the emotion that drives that
expressive behavior.
Fantasy: Tendency to retreat into fantasy in order to resolve inner
and outer conflicts.
Wishful thinking: Making decisions according to what might be
pleasing to imagine instead of by appealing to evidence, rationality,
or reality
Idealization: Tending to perceive another individual as having
more desirable qualities than he or she may actually have
Passive aggression: Aggression towards others expressed
indirectly or passively, often through procrastination.

Level 2: Immature
PROJECTION: Often termed as scapegoat defense
mechanism. The person rejects unwanted
characteristics of self and assigns them to others. He
may blame others for faults, feelings, or shortcomings
that are unacceptable to self.
Ex: 1. A man who is late for work states, My wife forgot
to set the alarm last night so I overslept.

2. A student who fails in an exam blames his

teacher for not discussing the topic properly

Level 2: Immature
Somatization: The transformation of
uncomfortable feelings towards others into
uncomfortable feelings toward oneself:
pain, illness, and anxiety.

Level 3: Neurotic
These mechanisms are considered neurotic, but fairly
common in adults.
Such defences have short-term advantages in coping,
but can often cause long-term problems in relationships,
work and in enjoying life when used as one's primary
style of coping with the world.

Level 3: Neurotic
DISSOCIATION: The act of separating and detaching a strong,
emotionally charged conflict from ones consciousness.
Ex: A woman who was raped was found wandering a busy
highway in torn clothing. When examined by the ER physician,
the woman was exhibiting symptoms of traumatic amnesia.
DISPLACEMENT
-A mechanism that serves to transfer feelings such as
frustration, hostility, or anxiety from one idea, person, or object
to another.
Ex: Slamming the door when you are angry
Or yelling at one person when you are angry at another

Level 3: Neurotic
Hypochondriasis: An excessive preoccupation or worry about
having a serious illness.
INTELLECTUALIZATION
-The act of transferring emotional concerns into the intellectual
sphere. The person uses reasoning as a means of avoiding
confrontation with unconscious conflicts and their stressful
emotions.
Ex: A young man shows no emotional response to the dear John
letter he received from his fiance; instead, he tells his roommate
he is trying to figure out why she changed her mind about the
upcoming wedding.

Level 3: Neurotic
ISOLATION
-The process of separating an unacceptable feeling,
idea, or impulse from ones thoughts (also referred to as
emotional isolation)
Ex: An oncologist is able to care for a terminally ill
cancer patient by separating or isolating his feelings or
emotional reaction to the patients inevitable death. He
focuses on the treatment, not the prognosis.

Level 3: Neurotic
RATIONALIZATION
-The most common ego defense mechanism. Referred to
as self-deception at its subtle best. It is used to justify
ideas, actions, or feelings with good, acceptable reasons
or explanations.
Ex: A teenaged girl who was not asked to the junior
prom tells her friend,

John really wanted to date me but felt sorry for

Ann and took her the prom.

Level 3: Neurotic
REACTION-FORMATION
- Also referred to as overcompensation. The person
exaggerates or overdevelops certain actions by
displaying exactly the opposite behavior, attitude, or
feeling from what he normally would show in a given
situation.
Ex: 1. A young man who dislikes his mother-in-law may
act very polite and courteous toward her.

Level 3: Neurotic
REGRESSION
-Retreating to past levels of behavior that reduce
anxiety, allow one to feel comfortable, and permit
dependency. The person has regressed to earlier
developmental levels to reduce feelings of anxiety.
Ex: 1. A 27 year old woman acts like a 17 year old on
her first date with a fellow employee.

2. A 5 year- old boy who is toilet trained becomes

incontinent during his fathers hospitalization.

Level 3: Neurotic
REPRESSION
-One of the most common defense mechanisms, referred to as the
burying alive mechanism. The person is unable to recall painful or
unpleasant thoughts or feelings because they are automatically and
involuntarily pushed into ones unconsciousness.
RESTITUTION OR UNDOING
-The negation of a previous consciously intolerable action or
experience to reduce or alleviate feelings of guilt.
Ex: A young man sends flowers to his fiance after he embarrassed
her at a cocktail party.

A young man who feels guilty of having another love affair with a
female regularly sends flowers to his girlfriend.

Level 3: Neurotic
Withdrawal:
Withdrawal is a more severe form of defence. It entails
removing oneself from events, stimuli, and interactions
under the threat of being reminded of painful thoughts
and feelings.

Level 4: Mature
These are commonly found among emotionally
healthy adults and are considered mature, even
though many have their origins in an immature
stage of development.
They have been adapted through the years in
order to optimise success in human society and
relationships.
The use of these defences enhances pleasure
and feelings of control.
These defences help to integrate conflicting
emotions and thoughts, whilst still remaining
effective.

Level 4: Mature
Respect: Willingness to show consideration or appreciation. Respect
can be a specific feeling of regard for the actual qualities of a person
or feeling being and also specific actions and conduct representative
of that esteem. Relationships and contacts that are built without the
presence of respect are seldom long term or sustainable. The lack of
respect is at the very heart of most conflict in families, communities,
and nations.
Moderation: The process of eliminating or lessening extremes and
staying within reasonable limits. It necessitates self-restraint which is
imposed by oneself on one's own feelings, desires etc.
Patience: The level of endurance under difficult circumstances
(delay, provocation, criticism, attack etc.) one can take before
negativity. Patience is a recognized virtue in many religions.

Level 4: Mature
Courage: The mental ability and willingness to confront conflicts,
fear, pain, danger, uncertainty, despair, obstacles, vicissitudes or
intimidation. Physical courage often extends lives, while moral
courage preserves the ideals of justice and fairness.
Humility: A mechanism by which a person, considering their own
defects, has a humble self-opinion. Humility is intelligent self-respect
which keeps one from thinking too highly or too meanly of oneself.
Acceptance: A person's assent to the reality of a situation,
recognizing a process or condition (often a difficult or uncomfortable
situation) without attempting to change it, protest, or exit. Religions
and psychological treatments often suggest the path of acceptance
when a situation is both disliked and unchangeable, or when change
may be possible only at great cost or risk.

Level 4: Mature
Gratitude: A feeling of thankfulness or appreciation involving
appreciation of a wide range of people and events. Gratitude is
likely to bring higher levels of happiness, and lower levels of
depression and stress. Throughout history, gratitude has been
given a central position in religious and philosophical theories.
Altruism: Constructive service to others that brings pleasure
and personal satisfaction.
Tolerance: The practice of deliberately allowing or permitting
a thing of which one disapproves.
Mercy: Compassionate behavior on the part of those in power.

Level 4: Mature
Forgiveness: Cessation of resentment, indignation or anger
as a result of a perceived offence, disagreement, or mistake,
or ceasing to demand retribution or restitution.
Anticipation: Realistic planning for future discomfort.
Humour: Overt expression of ideas and feelings (especially
those that are unpleasant to focus on or too terrible to talk
about directly) that gives pleasure to others. The thoughts
retain a portion of their innate distress, but they are "skirted
around" by witticism, for example self-deprecation.
Identification: The unconscious modelling of one's self upon
another person's character and behaviour.

Level 4: Mature
Introjection: Identifying with some idea or object so deeply that it
becomes a part of that person.
Sublimation: Transformation of unhelpful emotions or instincts into
healthy actions, behaviours, or emotions, for example, playing a
heavy contact sport such as football or rugby can transform
aggression into a game.
Suppression: The conscious decision to delay paying attention to
an emotion or need in order to cope with the present reality; making
it possible to later access uncomfortable or distressing emotions
whilst accepting them.
Emotional self-regulation: The ability to respond to the ongoing
demands of experience with the range of emotions in a manner that
is socially tolerable. Emotional self-regulation refers to the processes
people use to modify the type, intensity, duration, or expression of
various emotions.
Emotional self-sufficiency: Not being dependent on the validation
(approval or disapproval) of others.

PANIC DISORDER

:DEFINITION OF PANIC ATTACK

Periodic short bouts of panic
Sudden feelings of terror that occur suddenly and
without warning ,without any cause or precipitation
The Attacks occur in 50%-75% of cases during non REM sleep
( night panic) in addition to day occurrence

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Panic attacks
Onset
Most can recall the precise date ,time, nature and circumstances of
the first panic attack

Course
Frequency of attacks vary considerably between;
Few attacks in a life time.
Daily attacks for months ,then disappear and reappear.

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Panic attacks
Duration

From seconds to minutes in most cases, rarely it persists

for hours followed by exhaustion or headaches and
sometimes long sleep.

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Panic Attack criteria

The abrupt onset of an episode of intense fear or discomfort, which
peaks in approximately 10 minutes, and includes at least four of the
following symptoms:
A feeling of imminent danger or doom

The need to escape

Palpitations
Sweating
Trembling
Shortness of breath or a smothering
feeling
A feeling of choking
Chest pain or discomfort

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Nausea or abdominal discomfort

Dizziness or lightheadedness
A sense of things being unreal,
depersonalization
A fear of losing control or "going
crazy"
A fear of dying
Tingling sensations
Chills or hot flushes

There are three types of Panic Attacks

1. Unexpected - the attack "comes out of the blue"

without warning and for no discernable reason.
2. Situational - situations in which an individual
always has an attack, for example, upon entering a
tunnel.
3. Situationally Predisposed - situations in which an
individual is likely to have a Panic Attack, but does
not always have one. An example of this would be an
individual who sometimes has attacks while driving.

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Diagnostic Criteria: Panic Disorder

DSM-IV criteria

Recurrent unexpected panic attacks

A month or more of at least one of the following after an attack:
Persistent concern about having more attacks.
Worry about the implications or cause of attack.
Significant change in behavior related to attack.

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Diagnostic Criteria:
Panic Disorder
Absence or presence of agoraphobia
Panic attacks not due to substance or another mental
disorder
Various symptoms present with attacks

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Agoraphobia
Fear of the marketplace (agora) = fear of public areas (stores, theater, public
transport), fear of being away from safe places (home)
Hypothesis: almost exclusively a complication
of panic
Patient afraid of being caught somewhere
having a panic attack, where escape would be
difficult/impossible

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DIFERENTIAL DIAGNOSIS

MEDICAL CONDITIONS
1. Acute myocardial infarction
- in pure panic attacks patient doesn't
experience crushing chest pain

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DIFERENTIAL DIAGNOSIS
2. Catecholamine secreting tumors
( pheochromcytoma)
Severe Abdominal or Back pain
Hypertensive response to smoking
Malignant hypertensive episodes
Sweating in the chest and back while in panic in soles , palms
and forehead
Splitting headache

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DIFERENTIAL DIAGNOSIS
3.

Substance Abuse :
Cocaine.
Marijuana
Alcohol
Opiates

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DIFERENTIAL DIAGNOSIS
4.Hypoglycemia:Extremely rarely cause panic attacks
5. Caffeine:More than 700mg may cause panic attacks , also
patient with panic disorder may aggravate with one cup
of coffee.

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What You Can Do

Assessment
Intervention

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Assessment
Physical exam and baseline lab investigations should be
performed before initiation of pharmacological treatment

Regularly monitor weight changes and adverse effects of

medication, including sexual dysfunction

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Assessment
Explore the possibility of physical causes for
emotional symptoms
A physical exam should be part of the
assessment when new symptoms are present
Look for a history that does not fit
Review personal and family history carefully
Be suspicious if the onset of the disorder is
late in life

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Assessment
Be suspicious if there is a history of
recent onset of headaches, loss of
function, unusual perceptions
(tingling, dissociation, visual
disturbances, or
hallucinations- especially visual,
olfactory, or tactile)
Drugs, drugs, drugs.

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Baseline Lab Investigations

Urinanalysis
Complete blood
count (CBC)
Fasting glucose
Electrolytes
Liver enzymes
Serum bilirubin
Serum creatinine

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Urine toxicology for

substance use
24-hour creatinine
clearance
(if history of
renal disease)
Thyroid stimulating
hormone
Electrocardiogram
(>40 years or if
indicated)
Pregnancy test (if
relevant)
Prolactin

TREATMENT
IN Emergency Department
Most cases the attack exhausts itself within minutes but if it
persists An injectable form of benzodiazepines can be used

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Treatment of hyperventilation ..
Rebreathing
- An immediate treatment is to rebreathe expired air

from bag in order to increase the concentration of CO2 in

alveolar air

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Cognitive therapy
The two major foci of cognitive therapy for panic disorder
are : Instruction regarding the patient's false beliefs
( patient's tendency to misinterpret mild bodily sensations as
indicative of impending panic attack, doom or death)
Information regarding panic attacks
( when they occur , are time limited and not life-threatening)

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Behavioral and Cognitive Therapy

Teaches patient to react differently to situations and
bodily sensations that trigger anxiety
Teaches patient to understand how thinking patterns
that contribute to symptoms
Patients learn that by changing how they perceive
feelings of anxiety, the less likely they are to have them
Examples: Hyperventilating, writing down list of top
fears and doing one of them once a week, spinning in a
chair until dizzy; after awhile patients learned to cope
with the negative feelings associated with them and
replace them with positive ones

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Strategies to reduce anxiety

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Breathing exercises
Produce slow deep breathing
Prevent hyperventilation
Prevent excessive blowing off of CO2

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Meditation
Cultivates calmness to create a sense of control over life
Practice: Sit quietly in a position comfortable to you and take a
few deep breaths to relax your muscles, next choose a calming
phrase (such as om or that with great significance to you),
silently repeat the word or phrase for 20 minutes

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PHOBIA

Phobia
refers to a group of symptoms brought on by feared
objects or situations
People can develop phobic reactions to animals
,activities, or social situations.
affect people of all ages, from all walks of life, and in
every part of the country
can interfere with your ability to work, socialize, and go
about a daily routine

Symptoms
Feelings of panic, dread, horror, or terror
Recognition that the fear goes beyond normal boundaries
and the actual threat of danger
Reactions that are automatic and uncontrollable,
practically taking over the person's thoughts
Rapid heartbeat, shortness of breath, trembling, and an
overwhelming desire to flee the situation - all the physical
reactions associated with extreme fear
Extreme measures taken to avoid the feared object or
situation

Categories of Phobias
1. Agoraphobia
. fear of being alone in any place or
situation from which it seems
escape would be difficult or help
unavailable should the need arise
2. Social
. fears being watched or humiliated
while doing something in front of
others

Categories of Phobias
3. Specific
people with a specific phobia
generally have an irrational fear of
specific objects or situations

AGORAPHOBIA

AGORAPHOBIA
fear of experiencing a difficult or
embarrassing situation from which the
sufferer cannot escape
Agoraphobia occurs about twice as
commonly among women than men
(Magee et al., 1996
Agoraphobics are often extremely
sensitized to their own bodily
sensations, subconsciously overreacting to perfectly normal events

Symptoms
Fear of being alone
Fear of losing control in a public place
Fear of being in places where escape might be
difficult
Becoming housebound for prolonged periods of
time
Feelings of detachment or estrangement from
others
Feelings of helplessness
Dependence on others
Feeling that the body is unreal
Feeling that the environment is unreal
Anxiety or panic attack (acute severe anxiety)
Unusual temper or agitation with trembling or
twitching

Symptoms
Lightheadedness, near
fainting
Dizziness
Excessive sweating
Skin flushing
Breathing difficulty
Chest pain
Heartbeat sensations
Nausea and vomiting
Numbness and tingling
Confused or disordered
thoughts
Intense fear of going crazy
Intense fear of dying

Treatment
There are three main types of treatment for
agoraphobia:
1. Therapy
Behavior and cognitive therapy are the
treatments of choice for agoraphobia
2. Medications
antianxiety medication.
3. Combination of therapy and medications

SOCIAL PHOBIA

Social Phobia
an experience of fear, apprehension or worry regarding
social situations and being evaluated by others
excessive long-lasting social anxiety causing relatively
extreme distress and impaired ability to function in at
least some areas of daily life

Signs and Symptoms

Blushing
sweating (hyperhidrosis)
Trembling
Nausea
Stammering
Palpitations
shaking

Signs & Symptoms

dread over how they will be presented to others
overly self-conscious
have high performance standards
excessive social avoidance
substantial social or occupational impairment

Causes
Genetic and family factors
Social experiences
Social/cultural influences
Evolutionary context
Neurochemical and neurocognitive influences
Psychological factors

Treatment
Pharmacological treatments

Selective serotonin reuptake inhibitors (SSRIs)

monoamine oxidase inhibitors (MAOIs)
Reversible inhibitors of monoamine oxidase subtype A (RIMAs)
Benzodiazepines
beta-blockers

Treatments
Psychotherapy
cognitive-behavioral therapy
social skills training
Interpersonal Therapy

SPECIFIC
PHOBIA

Definition
extreme fear of a specific object or situation that is out
of proportion to the actual danger or threat
generic term for any kind of anxiet disorder that
amounts to an unreasonable or irrational fear related to
exposure to specific objects or situations

Signs & Symptoms

feelings of anxiety
Fear
panic
Tachycardia
Tachypnea
Hyperhydrosis
palpitations

Causes
Learning History
Direct Learning Experiences
Observational Learning Experiences
Informational Learning

Psychological Factors
Attention and Memory
Beliefs and Interpretations about Feared
Objects and Situations
Avoidance and other Anxious Behaviors

Biological Factors

Categories of Specific
Phobias
Animal Type
Natural Environment Type
Situational Type
Blood injection or Injury Type
Other

SPECIFIC PHOBIAS
Animal phobias: Examples include the fear of dogs, snakes, insects, or
mice. Animal phobias are the most common specific phobias.
Situational phobias: These involve a fear of specific situations, such as
flying, riding in a car or on public transportation, driving, going over
bridges or in tunnels, or of being in a closed-in place, like an elevator.
Natural environment phobias: Examples include the fear of storms,
heights, or water.
Blood-injection-injury phobias: These involve a fear of being injured, of
seeing blood or of invasive medical procedures, such as blood tests or
injections
Other phobias: These include a fear of falling down, a fear of loud sounds,
and a fear of costumed characters, such as clowns.

Examples
Ablutophobia- Fear of washing or bathing.
Acarophobia- Fear of itching or of the insects
that cause itching.
Acerophobia- Fear of sourness.
Achluophobia- Fear of darkness.
Acousticophobia- Fear of noise.
Acrophobia- Fear of heights.
Aerophobia- Fear of drafts, air swallowing, or
airbourne noxious substances.
Aeroacrophobia- Fear of open high places.
Aeronausiphobia- Fear of vomiting secondary
to airsickness.
Agateophobia- Fear of insanity.
Agliophobia- Fear of pain.
Agoraphobia- Fear of open spaces or of being
in crowded, public places like markets. Fear of
leaving a safe place.
Agraphobia- Fear of sexual abuse.
Agrizoophobia- Fear of wild animals.

Aichmophobia- Fear of needles or

pointed objects.
Ailurophobia- Fear of cats.
Albuminurophobia- Fear of kidney
disease.
Alektorophobia- Fear of chickens.
Algophobia- Fear of pain.
Alliumphobia- Fear of garlic.
Allodoxaphobia- Fear of opinions.
Altophobia- Fear of heights.
Amathophobia- Fear of dust.
Amaxophobia- Fear of riding in a car.

Treatment
Psychological Treatments
Exposure to Feared Situation/Systemic desensitization
Applied Muscle Tension
Cognitive Therapy

Biological treatments

PTSD
POST-TRAUMATIC STRESS DISORDER

POST-TRAUMATIC STRESS DISORDER (PTSD)

is an anxiety disorder characterized by reliving a psychologically
traumatic situation, long after any physical danger involved has
passed, through flashbacks and nightmares.

CAUSES
Genes
Brain Areas
Traumatic events
Other risk factors

CAUSES
War
Natural disasters
Car or plane crashes
Terrorist attacks
Sudden death of a loved one
Rape
Kidnapping
Assault
Sexual or physical abuse
Childhood neglect

CAUSES
Previous traumatic experiences, especially in early life
History of substance abuse
History of depression, anxiety, or another mental illness
Witnessing violent deaths

Being held hostage

High level of stress in everyday life
Lack of support after the trauma
Lack of coping skills

SIGNS & SYMPTOMS

Re-experiencing symptoms
Avoidance symptoms
Hyperarousal symptoms

SIGNS & SYMPTOMS

Re-experiencing symptoms
may cause problems in a persons everyday routine. They
can start from the persons own thoughts and feelings.
Words, objects, or situations that are reminders of the event
can also trigger re-experiencing.

SIGNS & SYMPTOMS

Avoidance symptoms
Things that remind a person of the traumatic event can
trigger avoidance symptoms. These symptoms may cause a
person to change his or her personal routine. For example,
after a bad car accident, a person who usually drives may
avoid driving or riding in a car.

SIGNS & SYMPTOMS

Hyperarousal symptoms
Hyperarousal symptoms are usually constant, instead of
being triggered by things that remind one of the traumatic
event. They can make the person feel stressed and angry.
These symptoms may make it hard to do daily tasks, such
as sleeping, eating, or concentrating.

WHO IS AT RISK?
It can occur at any age, including childhood. Women
are more likely to develop PTSD than men, and there is
some evidence that susceptibility to the disorder may run in
families.
Anyone can get PTSD at any age. This includes war
veterans and survivors of physical and sexual assault,
abuse, accidents, disasters, and many other serious events.
Not everyone with PTSD has been through a dangerous
event. Some people get PTSD after a friend or family
member experiences danger or is harmed. The sudden,
unexpected death of a loved one can also cause PTSD.

DIAGNOSIS
To be diagnosed with PTSD, a person must have all of the
following for at least 1 month:
At least one re-experiencing symptom
At least three avoidance symptoms
At least two hyperarousal symptoms

Symptoms that make it hard to go about daily life, go to school

or work, be with friends, and take care of important tasks.
PTSD is often accompanied by depression, substance abuse,
or one or more of the other anxiety disorders.

TREATMENTS
PSYCHOTHERAPY

MEDICATIONS

OTHER MEDICATIONS

Exposure therapy

Sertraline (Zoloft)

Benzodiazepines

Cognitive
restructuring

Paroxetine (Paxil)

Antipsychotics

Stress inoculation
training
Family therapy

Other antidepressants

Acute Stress Disorder

What is Acute Stress Disorder (ASD)?

ASD is an anxiety disorder characterized by a group of
dissociative and anxiety symptoms that occur within a month of
a traumatic event.
Traumatic events include: witnessing or experiencing rape or
other violent assaults; death, suffered a severe injury or natural
disaster, or a severe transport accidents.
The person's response involves intense fear, guiltiness,
helplessness, or horror.

What are the differences between

ASD and Post-Traumatic Stress
Disorder?
ASD and PTSD are both disorders that can occur following a
traumatic event.
ASD can be diagnosed between 2 days and 4 weeks after
exposure, where PTSD can only be diagnosed after 4 weeks have
passed.
In addition to the symptoms experienced in PTSD, ASD includes
symptoms of dissociation.
If left untreated, ASD is likely to advance into PTSD.

Symptoms:
Dissociative symptoms

Less aware of surroundings

Feeling numb or detached
Derealization
Depersonalization
Dissociative amnesia

Re-experiencing symptoms

Dreams
Illusions
Flashback
Intense distress

Other symptoms that indicate ASD

Sleeping problems
Difficulty concentrating
Irritability
Inability to do necessary tasks including seeking help
Feeling detached from others
Motor restlessness
Avoiding people or places that remind him/her about the event

Diagnosis
ASD is diagnosed by:
comparing the patient's symptoms to the DSM-IV and DSM-IV-TR
criteria
using the Acute Stress Disorder Scale

Treatment of Acute Stress Disorder

Medications
Psychotherapy
Alternative and complementary treatments

Medications
Prescribed antidepressants:
Sertraline
Paroxetine
Fluvoxamine
Citalopram
Clomipramine
For avoidance symptoms
Fluoxetine

Medications
To reduce anxiety and panic
Alprazolam
Diazepam
Clonazepam
Lorazepam
Propanol
For insomnia and nightmares
Trazodone
Topiramate

Psychotherapy
Cognitive-behavioral therapy
Gestalt Therapy
Psychoanalityc
Rational-Emotive Therapy
Behavior Therapy
Group and Family Therapies
Therapeutic Writing

Alternative and complementary treatments

Yoga
Meditation
Music Therapy
Hypnosis
Hydrotherapy
Traditional Chinese Medicine
Critical Incident Stress Management Program

Prognosis
80% of people diagnosed with ASD have
PTSD six months later; 75% will develop
symptoms of PTSD two years from the
traumatic event.

Treatment for children with ASD

Antidepressants:
Imipramine
Chloral hydrate
Cognitive Behavioral Therapy
Adjunctive Therapies
Family-Based Treatments
Group Therapy

OCD

Obsessive-Compulsive Disorder
affects almost 3% of worlds
population
Start anytime from preschool to
adulthood
Typically between 20-24y

many different forms of OCD differ

from person to person
cause of OCD is still unknown
Better when diagnosed early

Definition
Anxiety disorder with presence of obsessions or
compulsions
Must take up more than 1 hour a day
Must disrupt daily routine
Symptoms cant result from effects of other medical
conditions or substances

Obsessions
repetitive and constants thoughts, images, or
impulses that cause anxiety or distress
thoughts, images, or impulses not about real-life
problems
Try to ignore or counter act thoughts, images, or
impulses

Common Obsessions in OCD

Contamination:
Body fluids (examples: urine, feces)
Germs/disease (examples: herpes, HIV)
Environmental contaminants (examples: asbestos, radiation)
Household chemicals (examples: cleaners, solvents)
Dirt

Unwanted Sexual Thoughts:

Forbidden or perverse sexual thoughts or images
Forbidden or perverse sexual impulses about others
Obsessions about homosexuality
Sexual obsessions that involve children or incest
Obsessions about aggressive sexual behavior towards others

Compulsions
Repetitive behaviors or mental acts person
does in reaction to obsessions
behaviors or mental acts done to avoid or
decrease distress
behaviors or mental acts are clearly
excessive or not realistic

Common Compulsions in OCD

Washing and Cleaning:
Washing hands excessively or in a certain way
Excessive showering, bathing, tooth brushing, grooming or toilet routines
Cleaning household items or other objects excessively
Doing other things to prevent or remove contact with contaminants

Checking:
Checking that you did not/will not harm others
Checking that you did not/will not harm yourself
Checking that nothing terrible happened
Checking that you did not make a mistake
Checking some parts of your physical condition or body

History
14th & 15th century thought people were
possessed by the devil and treated by exorcism
17th century thought people were cleansing their
guilt
18th century finally considered medical issue
20th century began treating with behavioral
techniques

Theories
Scientist split into 2 groups
Psychological disorder were people are
responsible for feelings they have
Abnormalities in the brain

Causes
Serotonin is involved in regulating anxiety
Abnormality in the neurotransmitter serotonin
OCD suffers may have blocked or damaged receptor sites
preventing serotonin from functioning to full potential

Possible genetic mutation

Some people suffering have mutation in the human serotonin
transporter gene

Comorbidity
Has excessive comorbidity with other diseases
Common diseases: Depression, Schizophrenia, Tourette
Syndrome
Depression is the most common
Many people with OCD suffered from depression first
2/3 of OCD patients develop depression makes OCD
symptoms worse and more difficult to treat

People with OCD common diagnosed as Schizophrenic

hard to separate obsessions from delusions

Treatment
Only completely curable in rare cases
Most people have some symptom relief with treatment
Treatment choices depend on the problem and patients
preferences
Most common treatments:
Behavioral Therapy
Cognitive Therapy
Medication

Cognitive-Behavioral Therapy
Cognitive: change the way they think to deal with their
fears
Behavioral: change the way they react to anxietyprovoking situations
Exposure and Response Prevention
Slowly learning to tolerate anxiety associated with not
performing ritual behavior
Psychotherapy
Talking with therapist to discover what causes the
anxiety and how to deal with symptoms
Systematic Desensitization
Learning cognitive strategies to deal with anxiety then
gradual exposure to feared object

Cognitive-Behavioral Therapy
Should be done when people are ready for it
Must be customized for each persons specific form of OCD
and their needs
No side affects except increased anxiety with exposure to
fear
Often lasts about 12 weeks
If OCD returns can successfully treat again with same
therapy
Best treatment approach for most is CBT combined with
medication

Medication
Anxiolytic benzodiazepine such as chloradiazepoxide or diazepam give
temporary relief from anxiety but not really effective on obsessions and
compulsions
Antidepressants because of common depression
Selective Serotonin Reuptake Inhibitors (SSRIs): alter the levels of
neurotransmitter serotonin in the brain which helps brain cells communicate
with one another
Prevents excess serotonin from being pumped back into original neuron
that released it
Then can bind to receptor sites of nearby neurons and send chemical
message that can help regulate anxiety and obsessive compulsive thoughts
Most effective drug treatment helping about 60% of patients
Ex: Prozac, Zoloft, Lexapro, Paxil

Conclusion
OCD is a complicated issue
Most cases are incurable
Best form of treatment is CBT in
combination with medication

Chronic Anxiety Disorder

or Generalized Anxiety
Disorder

Chronic Anxiety Disorder or Generalized Anxiety Disorder

Excessive worry and anxiety for days but not

more than 6 months
Difficulty in controlling the worry
Anxiety and worry are evident by 3 or more of
the following :

Restlessness, Keyed up
Fatigue and irritability
Decreased ability to concentrate
Muscle tension
Disturbed sleep

Anxiety or worry causes significant impairment

in interpersonal relationship or activities of daily
living

Review Anxiolytic
Drugs!!!!

end