CH-11 Communication and the Clinical Interview – Varcaroliss Canadian Psychiatric Mental Health Nursing : Chapter Notes

Varcarolis’s Canadian Psychiatric Mental Health Nursing Chapter 11: Communication and the Clinical Interview Instructor’s Manual Thoughts About Teaching the Topic An essential task of the instructor is to help the student communicate effectively, adapt communication skills for the psychiatric mental health setting, and be responsive to the mental state and changing conditions of patients in practice. The more active the learner, the more easily the objectives seem to be operationalized. Independent study and readings may be used for initial learning, to be followed by in-class activities such as role-playing, the analysis of filmed material, or analysis and discussion of process recordings. Faculty often find that in a group, reinforcing use of therapeutic communication is more effective than dwelling on nontherapeutic student choices. Dramatizations, as in films, videos, or role-playing, followed by discussion, allow the learner to identify principles and analyze interactions. Written exercises and process recordings also allow learners to identify techniques and consider their effectiveness. The element of interactivity makes computer-assisted instruction and interactive video ideal media for teaching and reinforcing therapeutic communication techniques. The learner can work independently at his or her own pace without the fear of revealing lack of knowledge. If students use journals and submit them to the instructor, be sure to point out that this is one avenue for obtaining the supervision discussed in the chapter. Key Terms and Concepts active listening closed-ended questions cultural filters double messages double-bind messages feedback nontherapeutic communication techniques nonverbal behaviours nonverbal communication open-ended questions therapeutic communication skills and strategies verbal communication Instructor’s Manual 11-2 Objectives Identify three personal and two environmental factors that can impede communication. Discuss the differences between verbal and nonverbal communication, and identify five examples of nonverbal communication. Identify two attending behaviours the psychiatric nurse might focus on to increase communication skills. Compare and contrast the range of verbal and nonverbal communication of different cultural groups in the areas of communication style, eye contact, and touch. Give examples. Relate problems that can arise when nurses are insensitive to cultural aspects of patients’ communication styles. Demonstrate the use of four techniques that can enhance communication, highlighting what makes them effective. Demonstrate the use of four techniques that can obstruct communication, highlighting what makes them ineffective. Identify and give rationales for suggested setting, seating, and methods for beginning the psychiatric nurse–patient interaction. Explain to a classmate the importance of clinical supervision. Chapter Outline Teaching Strategies The Communication Process Communication is the process of sending a message to one or more persons. Berlo’s model explains the communication process and identifies the following: The stimulus—reason for beginning communication The sender—initiates the interpersonal contact The message—the information sent The media—how the information is sent (auditory, tactile, smell, or any combination of these) The receiver—receives and interprets the message The feedback—receiver’s response to the sender Factors That Affect Communication Factors that can distort sending and receiving messages include the following: Personal factors, which include emotional, social, and cognitive factors, such as mood, previous experience, cultural differences, knowledge levels, and language use Environmental factors, which include physical and societal factors, such as noise, lack of privacy, uncomfortable surroundings, presence of others, and expectations of others Relationship factors, which refer to whether the participants are equal. Peplau’s principles to guide communication during the nurse–patient interview are clarity and continuity. Verbal Communication Verbal communication consists of all words a person speaks. When we speak, we communicate beliefs and values, perceptions and meanings; convey interest and understanding or insult and judgement; convey messages clearly or convey conflicting or implied messages; convey clear, honest feelings or disguised, distorted feelings. Words have different meanings for different people (e.g., the word “trip” may produce a number of different mental images). Nonverbal Communication Nonverbal communication consists of behaviours displayed by an individual to express thoughts or feelings (e.g., tone of voice, manner, facial expression, body posture, eye contact, eye cast, hand gestures, sighs, fidgeting, and yawning). Interpretation of nonverbal communication depends on culture, class, gender, age, sexual orientation, and spiritual norms. Interaction of Verbal and Nonverbal Communication The verbal message is considered the content; the nonverbal message is considered the process. It is desirable for verbal and nonverbal messages to be congruent. If the verbal message is not reinforced or is contradicted by the nonverbal message, the message is confusing. Such an occurrence is called a double or mixed message. Therapeutic Communication Techniques Table 11-3 Using Silence Use of silence can be a significant means of influencing and being influenced by others. Possible meanings of a patient’s silence include emotional blocking, unreadiness to disclose, anger or hostility, insult, and acknowledgment of a nurse’s lack of cultural sensitivity. The nurse’s silence can indicate willingness to let the patient set the pace, can communicate strength and support as a patient regains composure, or can provide an opportunity to think. Active Listening Active listening includes observing a patient’s nonverbal behaviours, listening to and understanding a patient’s verbal message, listening to and understanding the person in the context of the social setting of his or her life, and listening for inconsistencies or things the patient says that need clarification. Ability to listen is affected by cultural filters that influence when to listen and what to ignore. These filters introduce cultural bias into our listening. Active listening helps patients use their abilities to solve problems, clarify thinking, and link ideas. It also enhances patient self-esteem. Listening With Empathy Wheeler (2008) identifies empathy as the most important element in therapeutic communication. It is not enough for the nurse to feel empathy; an important part of this process is that empathy is communicated to the patient (Egan, 2007). Clarifying Techniques Use of clarifying techniques allows the nurse to seek verification from the patient regarding the nurse’s interpretation of the patient’s messages. Paraphrasing—Paraphrasing is restating the basic content of a message using different words. Restating—Restating is repeating the same key words the patient has just spoken. Reflecting—Reflecting takes the form of a question or simple statement that conveys the nurse’s observations of the patient when sensitive issues are discussed. Exploring—Exploring is asking the patient to tell you more; to describe or give an example. Asking Questions and Eliciting Patient Responses Questions or statements can be classified as open-ended, focused, or closed-ended and may be placed along a continuum of openness. Three variables influence placement on the continuum of openness: the degree to which the verbalization produces a spontaneous and lengthy response, the degree to which the verbalization does not limit the patient’s answer set, and the degree to which the verbalization opens up a moderately resistant patient. Open-ended questions require more than one-word answers. Open-ended questions are valuable as opening phrases of any interview and work well with resistant or guarded patients. Closed-ended questions ask for specific information and limit the patient’s freedom to give lengthy answers. Nontherapeutic Communication Techniques Excessive Questioning Asking many questions, especially closed-ended questions, puts the nurse in the role of interrogator. This role conveys lack of respect for and insensitivity to patient needs. Giving Approval or Disapproval Giving approval or disapproval usually involves a value comment that may easily be misinterpreted by the patient. The patient may read this behaviour as a way to please the nurse and continue it for that reason rather than of his or her own volition. Giving Advice Advising is rarely helpful to patients; it interferes with their ability to make personal decisions and may undermine patient confidence. Instead, seek the patient’s opinion regarding actions he or she can take. Asking “Why” Questions “Why” questions often imply criticism and can lead to rationalization. Instead, ask the patient what is happening. Cultural Considerations The nurse’s awareness of cultural meanings of certain verbal and nonverbal communications in initial face-to-face encounters with a patient can lead to the formation of a positive therapeutic relationship (Kavanaugh, 2003). Unrecognized differences in cultural identities can result in assessment and interventions that are not optimally respectful of the patient and can be inadvertently biased or prejudiced. Nurses need to have not only knowledge of various patients’ cultures but also awareness of their own cultural identities. Especially important are nurses’ attitudes and beliefs toward those from cultures other than their own because these will affect their relationships with patients. Four areas that may prove problematic for the nurse trying to interpret specific verbal and nonverbal messages of the patient include the following: Communication style Use of eye contact Perception of touch Cultural filters Further information about working with people of various cultures is presented in Chapter 7. The Clinical Interview The clinical interview is a systematic attempt to understand those problems in patients’ lives that interfere with meeting their goals and to help them improve their skills or learn alternative ways of dealing effectively with their problems. The content and direction of the clinical interview are decided by the patient. The patient leads. The nurse employs communication skills and active listening, observes how congruent the content is with the process, and provides the opportunity for the patient to reach specific goals. How to Begin the Interview Pace—Extremely important to any kind of counselling is permitting the patient to set the pace of the interview, no matter how slow or halting the progress may be (Arnold & Boggs, 2007). Setting—A setting that enhances feelings of security is best. Strive for relative privacy. Seating—Seating should be arranged so that conversation can take place in normal tones and eye contact can be comfortably maintained or avoided by placing chairs at a 90- or 120-degree angle or side by side. Avoid a desk “barrier” between nurse and patient. The door should be accessible to both. Introductions—Nurses tell the patient who they are, their school name, the purpose of the meeting, and how long and when they will meet. They ask how the patient would like to be addressed. Confidentiality should be addressed at some point. Initiating the interview—After introductions, give the patient the lead by using an open-ended statement. Facilitate communication using general leads, statements of acceptance, and other therapeutic techniques. Tactics to avoid—Avoid arguing, minimizing the patient’s problem, praising, giving false reassurance, interpreting or speculating on dynamics, probing, joining in if patient verbally attacks a significant person in his or her life, criticism of a staff member, and “selling” the patient on treatment. Helpful guidelines—Speak briefly; say nothing when you don’t know what to say; when in doubt, focus on feelings; avoid giving advice and relying on questions; note nonverbal cues; and keep the focus on the patient. Attending behaviours—Engaging in attending behaviours and actively listening are two key principles of counselling. Eye contact—Sommers-Flanagan and Sommers-Flanagan (2003) state that in most situations, it is appropriate for nurses to maintain more eye contact when the patient speaks and less constant eye contact when the nurse speaks. Body language—This involves two elements: kinesics, body movements and postures, and proxemics, significance of physical distance between individuals. Vocal quality—This encompasses loudness, pitch, rate, and fluency. Verbal Tracking—Giving neutral feedback in the form of restating or summarizing what the patient has said. Clinical Supervision and Process Recordings Working with a supervisor to examine one’s interactions, obtain insights, and devise effective strategies for dealing with clinical issues enhances a nurse’s professional growth and minimizes burnout. Clinical supervision methods can include analyzing a videotape, audiotape, or process recording of an interaction. Varcarolis’s Canadian Psychiatric Mental Health Nursing Chapter 12: Understanding Responses to Stress Instructor’s Manual Thoughts About Teaching the Topic The instructor may choose to spend time emphasizing and clarifying concepts discussed in the chapter concerning the relationship of stress and altered physiological function, the relationship of stress and anxiety, and the nurse’s role in helping the patient identify stressors and develop healthy approaches to coping with stress. Students often bring up examples from their personal lives to emphasize the continuum of mental health and illness. The instructor may also wish to have students explore the relationship between stress and student success or professional burnout. Key Terms and Concepts Benson’s relaxation technique cognitive reframing coping styles distress eustress fight-or-flight response general adaptation syndrome (GAS) guided imagery journaling meditation mindfulness physical stressors progressive muscle relaxation (PMR) psychological stressors psychoneuroimmunology stressors Objectives Recognize the short- and long-term physiological consequences of stress. Compare and contrast Cannon’s fight-or-flight response, Selye’s general adaptation syndrome, and the psychoneuroimmunological models of stress. Describe how responses to stress are mediated through perception, personality, social support, culture, and spirituality. Assess stress level using the Recent Life Changes Questionnaire. Identify and describe holistic approaches to stress management. Instructor’s Manual 12-2 Teach a classmate or patient a behavioural technique to help lower stress and anxiety. Explain how cognitive techniques can help increase a person’s tolerance for stressful events. Chapter Outline Teaching Strategies Responses to and Effects of Stress Early Stress Response Theories Stress is a universal experience. Selye initially defined stress as the unspecific result of any demand upon the body and expanded Cannon’s theory of stress with his formulation of the general adaptation syndrome (GAS). GAS occurs in two stages: (1) an initial adaptive response (fight or flight), or acute stress, and (2) the eventual maladaptive consequences of prolonged stress. Later, Selye distinguished between distress, which is destructive to health, and eustress, which is beneficial stress that motivates energy. Neurotransmitter Stress Responses Serotonin plays an important role in mood, sleep, sexuality, appetite, and metabolism. 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 impair serotonin receptor sights and the brain’s ability to use serotonin (Sadock & Sadock, 2008). Immune Stress Responses Studies in psychoneuroimmunology continue to provide evidence that stress, through the hypothalamic–pituitary–adrenal and sympathetic– adrenal medullary axes, can induce changes in the immune system. Stressors Two categories of stressors exist: (1) physical, exemplified by environmental conditions such as cold, trauma, excessive heat, and physical conditions such as infection, hemorrhage, hunger, or pain; (2) psychological, exemplified by divorce, job loss, unmanageable debt, death of a loved one, retirement, marriage, unexpected success. Mediators of the Stress Response Mediating factors include age, sex, culture, life experiences, lifestyle, and social support. Researchers have found that the perception of a recent life event determines the person’s reactions to it. Each person has a unique personality that reacts to and copes with stress with specific strengths and vulnerabilities. Self-help groups are a means of providing social support. Ideally, high-quality social support should be provided, since research tells us it is linked with high satisfaction. High-quality support relationships are free from conflict and negative interactions; they are close, confiding, and reciprocal. Low-quality support relationships may negatively affect a person’s coping effectiveness in a crisis. Culture Culture plays a role in determining what is considered dangerous, how to manage violations of social code, what reactions are permissible in given experiences, how a stressful event is appraised, and how emotion generated by the event should be expressed. Culture plays a role in how people experience stressors in their lives and what interventions will be useful. The majority of Asian, African, and Central American peoples express subjective distress in somatic terms, rendering psychological interpretations less useful. Instructor’s Manual 12-3 Spirituality and Religious Beliefs Religious and spiritual beliefs are helpful for many people coping with stress. Studies have demonstrated that spiritual practices can enhance the immune system and sense of well-being. Nursing Management of Stress Responses Measuring Stress Since 1999, Statistics Canada and the Canadian Institute for Health Information have collaborated on developing and providing a broad range of indicators of health focusing on demography, health status, health behaviours, and the environment. The Recent Life Changes Questionnaire is available for self-rating. Recent findings suggest that life stress over the last 35 years has increased markedly. Other findings note there is a gender difference in the way in which certain factors such as finances are rated. Assessing Coping Styles Rahe identifies four categories of coping styles that people use as stress buffers: (1) health-sustaining habits, (2) life satisfactions, (3) social supports, and (4) response to stress. Nurses evaluate these to identify areas to target for improvement. Coping strategies include psychological defence mechanisms, psychophysiological defences that are in our awareness (e.g., headache) or out of awareness (hypertension or depression). Holistic Approaches to Stress Management Benefits of stress reduction include altering the course of medical conditions such as hypertension; decreasing need for medications such as antihypertensives; diminishing or eliminating the need for unhealthy behaviours such as smoking; increasing cognitive functions such as learning; breaking up static patterns of thinking to allow creative perceptions of events; and increasing sense of well-being via endorphin release. Behavioural Methods Cognitive-behavioural methods are the most effective ways to reduce stress. Behavioural methods include a number of relaxation techniques. Benson’s Relaxation Techniques Benson’s relaxation technique allows patients to switch from the sympathetic mode of autonomic arousal to the parasympathetic mode of relaxation; it can be learned with practice. Relaxation techniques should be used with physician approval. They may not be appropriate for use by depressed, hallucinating, or delusional patients or by those in severe pain. Box 12-2 Meditation Meditation is mind training to develop greater calm, increased relaxation, and the ability to access inner resources for both healing and operating more effectively in the world. Guided Imagery Guided imagery is used in conjunction with the relaxation response. A person is led to envision images that are calming and health enhancing. Imagery techniques are useful for pain relief and for reducing levels of cortisol, epinephrine, and catecholamines, thus supporting the immune system and producing -endorphins (which increase the pain threshold and enhance lymphocyte proliferation). Box 12-3 Breathing Exercises Learning abdominal breathing can be helpful in the modification of stress and anxiety reactions. Box 12-4 Physical Exercise Exercise can lead to protection from the harmful effects of stress on both physical and mental states. Regular exercise was associated with Instructor’s Manual 12-4 lower incidence of all psychiatric disorders except bipolar disorder and co-morbid conditions in subjects aged 14 to 24 in a study by Strohle and colleagues (2007). Progressive Muscle Relaxation Yoga can reduce stress and relieve muscle tension and pain. Another technique, called progressive muscle relaxation (PMR), achieves deep relaxation by systematically tensing and releasing various muscle groups. Biofeedback Biofeedback uses sensitive instrumentation that gives a person information on his or her physiological functions, such as brain waves, skin temperature, and blood pressure, to help the individual gain control over what had been considered involuntary functions. Cognitive Approaches Cognitive Reframing Cognitive reframing includes restructuring of irrational beliefs and replacing worried self-statements with more positive self-statements. Essentially, reframing is reassessing a situation. Restructuring a disturbing event to one that is less disturbing gives the patient a sense of control, reduces sympathetic nervous system stimulation, and in turn reduces secretion of cortisol and catecholamines. Mindfulness To become mindful, practitioners suggest observing and monitoring the content of our consciousness and recognizing that thoughts are just thoughts. Negative interpretations can become positive when mindfulness is practised. Journaling Keeping an informal diary of daily events and activities helps identify sources of daily stress. The individual can then take measures to modify or eliminate the stressors. Humour The intensity attached to a stressful thought or situation can be dissipated when it is made to appear absurd or comical. Varcarolis’s Canadian Psychiatric Mental Health Nursing Chapter 13: Anxiety, Obsessive-Compulsive, and Related Disorders Instructor’s Manual Thoughts About Teaching the Topic It is helpful for students to review each of the disorders and then, via discussion and questioning, to focus on similarities and differences in order to distinguish the specific symptoms and treatments for the distinct disorders. When time is limited, faculty may wish to assign chapters on the anxiety disorders and the somatoform and dissociative disorders together, or include eating disorders or even stress or crisis within this topic. When the topics are combined, the focus in classroom activities can be on commonly used nursing diagnoses and interventions. Key Terms and Concepts acute stress disorder agoraphobia anxiety compulsions fear flashbacks GABA-benzodiaxapine theory generalized anxiety disorder (GAD) mild anxiety moderate anxiety normal anxiety obsessions panic panic attack panic disorder (PD) post-traumatic stress disorder (PTSD) selective inattention severe anxiety social phobia specific phobias substance-induced anxiety disorder Objectives Compare and contrast the four levels of anxiety in relation to perceptual field, ability to learn, and physical and other defining characteristics. Identify defence mechanisms and consider one adaptive and one maladaptive use of each. Identify genetic, biological, psychological, and cultural factors that may contribute to anxiety disorders. Describe clinical manifestations of each anxiety disorder. Formulate four appropriate nursing diagnoses that can be used in providing care to a person with an anxiety disorder. Identify three defence mechanisms commonly found in patients with anxiety disorders. 7. Describe feelings that may be experienced by nurses caring for patients with anxiety disorders. Propose realistic outcome criteria for a patient with (a) generalized anxiety disorder, (b) panic disorder, and (c) post-traumatic stress disorder. Describe five basic nursing interventions used for patients with anxiety disorders. Discuss three classes of medications appropriate for the treatment of anxiety disorders. Describe advanced-practice and basic-level interventions for anxiety disorders. Chapter Outline Teaching Strategies Clinical Picture Anxiety Anxiety is a universal human experience. Dysfunctional behaviour is often a defence against anxiety. Anxiety, a feeling of apprehension, uneasiness, uncertainty, or dread resulting from a real or perceived threat whose actual source is unknown or unrecognized, can be differentiated from fear. Fear is a reaction to a specific danger. The body, however, reacts in physiologically similar ways to both fear and anxiety. Normal anxiety provides the energy to carry out tasks involved with living and striving toward goals (e.g., studying, beginning work on time, working toward a promotion). Acute anxiety, or state anxiety, is precipitated by imminent loss or change threatening the individual’s sense of security. Chronic anxiety, or trait anxiety, is anxiety that one has lived with for a long time. Levels of Anxiety Mild Anxiety Occurs in the normal experience of everyday living. Ability to perceive is in sharp focus and problem solving becomes more effective. Slight discomfort, restlessness, or mild tension-relieving behaviours may be observed. Moderate Anxiety Perceptual field narrows; some details are excluded from observation. Selective inattention may be experienced. Problemsolving ability is reduced but may be improved in the presence of a supportive person. Physical symptoms include tension, pounding heart, increased pulse and respiration rate, diaphoresis, and mild somatic symptoms. Severe Anxiety Perceptual field is greatly reduced. Learning and problem solving are not possible, and the person may appear dazed and confused, experience a sense of doom, and have intensified somatic complaints. Panic Results in markedly disturbed behaviour, inability to process environmental stimuli. The person might lose touch with reality and experience hallucinations. Physical behaviour may be erratic, uncoordinated, and impulsive. Automatic behaviours are used to reduce and relieve anxiety. Defences Against Sigmund Freud and his daughter, Anna Freud, outlined most of the Anxiety defence mechanisms we recognize today. Defence mechanisms are automatic psychological processes that protect the individual against anxiety and from the awareness of internal or external dangers or stressors. These relief behaviours are used by everyone to lower anxiety, maintain ego function, and protect the sense of self. Maladaptive use may lead to distortions in reality and selfdeception. Anxiety Disorders The common element of these disorders is that those affected experience a degree of anxiety so high that it interferes with personal, occupational, or social functioning. Panic Disorders Recurrent, unexpected panic attacks of sudden onset are a clinical symptom of this disorder. Physical symptoms of sympathetic arousal are accompanied by terror, limited perceptual field, and severe personality disorganization. Panic Disorder Without Agoraphobia This is characterized by recurrent unexpected panic attacks about which the individual is persistently concerned. Panic Disorder With Agoraphobia Clinical picture for this disorder is recurrent panic attacks accompanied by fear of being in an environment or situation from which escape might be difficult or embarrassing or in which help may not be available (e.g., being alone outside; being home alone; travelling in a car, bus, or plane; being on a bridge or in an elevator). Simple Agoraphobia Simple agoraphobia is fear of being in an environment or situation from which escape might be difficult (as listed above). Phobias Phobias are persistent, irrational fears of a specific object, activity, or situation that lead to a desire for avoidance or actual avoidance of the specific object or situation. Specific phobias are provoked by a specific object (e.g., a dog or spider) or situation (e.g., a storm); they are common and usually do not cause much difficulty because people can avoid the situation or object. Social phobia, or social anxiety disorder, is provoked by exposure to a social situation or a performance situation and can cause great difficulty. ObsessiveCompulsive and Related Disorders Obsessions are thoughts, impulses, or images that persist and recur and that cannot be dismissed from the mind. Compulsions are ritualistic behaviours that an individual feels driven to perform to reduce anxiety. They can be seen separately but usually coexist. The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) includes a new chapter on obsessivecompulsive and related disorders to reflect the increasing evidence of these disorders’ relatedness to one another and distinction from other anxiety disorders, as well as to help clinicians better identify and treat individuals suffering from these disorders. Disorders in this chapter of DSM-5 include obsessive-compulsive disorder, body dysmorphic disorder and trichotillomania (hair-pulling disorder), as well as two new disorders: hoarding disorder and excoriation (skinpicking) disorder. Generalized Anxiety Disorder Generalized anxiety disorder (GAD) is characterized by the presence of excessive anxiety or worry lasting for 6 months or longer; symptoms can include poor concentration, tension, sleep disturbance, and restlessness. Post-Traumatic Stress Disorder PTSD involves re-experiencing a highly traumatic event involving actual or threatened death or serious injury to self or others to which the person responded with intense fear or helplessness. Symptoms usually begin within 3 months after the traumatic incident and include flashbacks, persistent avoidance of stimuli associated with the trauma, numbness or detachment, and increased arousal. Acute Stress Disorder This occurs within 1 month after exposure to a highly traumatic event, such as described for PTSD. For the diagnosis of acute stress disorder, an affected individual must display three dissociative symptoms during or after the event (e.g., numbness, detachment, derealisation, depersonalization, or dissociative amnesia). Substance-Induced Anxiety Disorder Symptoms of anxiety, panic attacks, obsessions, and compulsions that develop with the use of a substance or within a month of stopping use. Anxiety Due to Medical Condition Symptoms of anxiety are sometimes the physiological result of a medical condition such as pheochromocytoma, cardiac dysrhythmias, hyperthyroidism, and the like. Anxiety Disorder Not Otherwise Specified This is a diagnosis used for disorders in which anxiety or phobic avoidance predominates, but the symptoms do not meet full diagnostic criteria for a specific anxiety disorder. Attention DeficitHyperactivity Disorder Attention deficit-hyperactivity disorder (ADHD) in adults is now well established as a recognized disorder (Castellanos & Tannock, 2002), with a prevalence of 4.4%. Most adults who seek out a referral for assessment do so upon the diagnosis of their own child or someone they know. Adults with ADHD may present with a primary complaint that is an associated symptom, such as procrastination, disorganization, lack of motivation, insomnia, rage attacks, or labile moods (CADDRA, 2011). Currently, treatment of ADHD in adults is either not available or not adequate. Adult ADHD represents a significant health care need requiring physician and nursing education, the establishment of services within the health care system, and appropriate research on treatment and service delivery. Epidemiology Anxiety disorders are the most common form of psychiatric disorders in Canada. In 2002, 4.7% of Canadians over the age of 15 years reported symptoms of anxiety in the previous 12 months. Of these, 1.6% met the criteria for panic disorder, 0.7% for agoraphobia, and 3.0% for social anxiety disorder. A full 11.5% of Canadian adults (more than 1 in 10) reported symptoms that indicated an anxiety disorder during their lifetime: 3.7% reported they had experienced panic disorder; 1.5%, agoraphobia; and 8.1%, social anxiety disorder. Social anxiety disorder is clearly the most common anxiety disorder in this country. Co-Morbidity Clinicians and researchers have clearly shown that anxiety disorders frequently co-occur with other psychiatric problems. Several studies suggest that other psychiatric disorders coexist about 90% of the time in people with generalized anxiety or panic disorder, 84% in those with agoraphobia, and about 70% in those with PTSD (Sadock & Sadock, 2008). Anxiety disorders are comorbid with major depression at a rate of 60%; in this type of comorbidity, anxiety symptoms tend to present before depressive symptoms. In fact, treatments for both disorders are similar, leading to speculation that, genetically, anxiety and depression may be two sides of the same coin and not distinct disorders (Kendler, Gardner, Gatz, et al., 2007). Etiology There is no longer any doubt that biological factors predispose some individuals to pathological anxiety states (e.g., phobias, panic attacks). However, traumatic life events, psychological factors, and sociocultural factors are also etiologically significant. Application of the Nursing Process Assessment General Assessment of Symptoms Patients prone to anxiety disorders are encountered in a variety of community settings. Assessment will usually involve determining if the anxiety is from a secondary source (medical condition) or a primary source (anxiety disorder). Symptoms specific to various anxiety disorders include panic attacks, phobias, obsessions, and compulsions. A number of rating scales are used in practice to assist accurate assessment. Self-Assessment Nurses’ feelings may include tension or anxiety, frustration, anger, being overwhelmed, fatigue, desire to withdraw, and guilt related to having negative feelings. Assessment Guidelines (1) Physical and neurological examinations will help determine if anxiety is primary or secondary. (2) Assess for potential for selfharm and suicide. (3) Do a psychosocial assessment to identify problems that should be addressed by counselling. (4) Note that cultural differences can affect the way in which anxiety is manifested. Diagnosis Useful nursing diagnoses include, but are not limited to Anxiety, Ineffective coping, Disturbed thought processes, Chronic low selfesteem, Situational low self-esteem, Powerlessness, Deficient diversional activity, Social isolation, Ineffective role performance, Ineffective health maintenance, Disturbed sleep pattern, Self-care deficit, Imbalanced nutrition, and Impaired skin integrity (North American Nursing Diagnosis Association International, 2009). Table 13-9 Outcomes Identification Useful outcome criteria describe the patient’s state or the situation expected to be influenced by nursing interventions. Nursing Outcomes Classification (NOC) is suggested as a resource. Examples of outcomes for anxiety control include the following: patient will monitor intensity of anxiety, eliminate precursors of anxiety, seek information to reduce anxiety, plan successful coping strategies, use relaxation techniques, report adequate sleep, report decrease in frequency of episodes, and so forth. Table 13-10 Planning Planning usually involves selecting interventions that can be implemented in a community setting, since patients with anxiety disorders are not usually hospitalized in an inpatient psychiatric unit. Patients with mild or moderate anxiety should be encouraged to be involved in planning, whereas for patients with severe anxiety, the nurse will need to take a more directive role. Implementation Overall guidelines for interventionsNurses need to (1) identify community resources that can offer the patient effective therapy, (2) identify community support groups for people with anxiety disorders, (3) assess need for interventions for families and significant others, (4) provide thorough teaching when medications are used. Table 13-11, Box 13-1 Mild to Moderate Levels of Anxiety The nurse can help the patient focus and solve problems with the use of specific communication techniques. Other helpful interventions include providing a calm presence, recognition of the person’s distress, and willingness to listen. Counsellors of patients with mild to moderate anxiety help patients focus and problem solve by using communication techniques such as open-ended questions, broad openings, and clarification seeking. Counsellors maintain a calm presence; they recognize the person’s distress and show willingness to listen. Severe to Panic Levels of Anxiety A person with a severe to panic level of anxiety is unable to solve problems, may not fully understand what is happening, and may not be in control of his or her actions. The nurse is concerned about patient safety and the safety of others. Physical needs (fluids, rest) must be met to prevent exhaustion. A quiet environment is best, and medications and restraints may be used after less restrictive interventions have failed. Themes in conversation may be identified. Counsellors communicate via firm, short, simple statements; point out reality if there are distortions; reduce environmental stimuli; provide a safe environment; and meet physical needs. Table 13-12 Counselling To assist patients to improve or regain coping abilities, counselling is often combined with other therapies. Milieu Therapy If the patient with an anxiety disorder does require hospitalization, the environment should be structured to offer safety and predictability, should have activities to shift the patient’s focus from his or her anxiety and symptoms, and should provide therapeutic interactions. Promotion of SelfCare Activities Patients with anxiety disorders can usually meet their own basic physical needs. Self-care activities most likely to be affected are discussed below. Nutrition and Fluid Intake For patients with OCD who are involved with their rituals to the exclusion of all else, nutrition and fluid intake could be affected. Assess weight and encourage intake. Personal Hygiene and Grooming Excessive neatness, rituals associated with bathing and grooming, and indecision are common among patients with phobias and OCD. Skin integrity may be a problem when rituals involve washing. Elimination Patients with OCD may suppress urges to void and defecate. Sleep Anxious patients often have difficulty sleeping. Patients with GAD, PTSD, and stress disorder may have nightmares. See Chapter 21. Pharmacological Interventions Antidepressants Selective serotonin reuptake inhibitors (SSRIs) are the first-line treatment for anxiety disorders. They are more prevalent than the tricyclic antidepressants (TCAs) because of their more rapid onset of action and fewer problematic adverse effects. Monoamine oxidase inhibitors (MAOIs) are reserved for treatment-resistant conditions because of the life-threatening risks from hypertensive crisis. With MAOIs, there are many dietary restrictions as well, which can also lead to difficulties for patients. Also effective for treatment of anxiety is venlafaxine (Effexor), which is a serotoninnorepinephrine reuptake inhibitor (SNRI). Antidepressants have the secondary value of treating co-morbid depressive disorders in patients but should be used with caution because of untoward effects if the patient suffers from another psychiatric or alcohol or drug disorder, which can be adversely affected by the antidepressants. Antianxiety Drugs These reduce anxiety to allow patients to participate in therapies directed at underlying problems. Benzodiazepines may be prescribed only for short periods of time because they are habituating. Accumulation of active metabolites can lead to increased sedation, decreased cognitive function, and ataxia. Buspirone (Bustab) is a nonbenzodiazepine and does not cause dependence. It may take 2 to 4 weeks for full effects to become apparent. Other Classes of Medication The -blockers are useful for treatment of social anxiety disorder and panic disorder. Antihistamines are a safe, nonaddictive alternative to benzodiazepines to lower anxiety levels, and again are helpful in treating patients with substance abuse problems. Integrative Therapy Chapter 37 identifies a number of complementary practices or integrative therapies that people use to cope with stress in their lives. Herbal and complementary therapy is popular in Canada; however, herbs and dietary supplements are not subject to the same rigorous testing as prescription medications. Also, herbs and dietary supplements are not required to be uniform, and there is no guaranteed bioequivalence of the active compound among preparations. Certainly exercise and outdoor activity have proven benefits and should be encouraged. Health Teaching Whether in the community or hospital setting, nurses can teach patients about signs and symptoms, offer theories about causes and risks, and provide information about interventions such as relaxation exercises, medications, and other approaches to alleviating anxiety. Advanced-Practice Interventions These nurses use several cognitive and behavioural treatment approaches such as systematic desensitization, thought stopping, relaxation training, and modelling. Cognitive and Behavioural Therapies Cognitive therapy—Assumes that cognitive errors made by the patient produce negative beliefs that persist. Counselling calls for the nurse to assist the patient to identify these thoughts and negative beliefs and to appraise the situation realistically. Cognitive restructuring—This therapy calls for the nurse to assist a patient to identify automatic negative anxiety-arousing thoughts and negative self-talk, discover the basis for the thoughts, and assist the patient to appraise the situation realistically and replace automatic thoughts and negative self-talk with realistic thinking. Cognitive-behavioural therapy—Uses a variety of approaches such as psychoeducational methods, continuous panic self-monitoring, breathing retraining, development of anxiety management skills, and in vivo exposure to feared stimuli. Relaxation training—Teaching muscle relaxation results in reduction of tension and anxiety. Modelling—Shows patient how an individual copes effectively and expects the patient to imitate the adaptive behaviour. Systematic desensitizationGraduated exposure gradually introduces the patient to a phobic object or situation in a predetermined sequence of least to most frightening. Teaches the patient to use a relaxation technique for anxiety management. Flooding (implosion therapy)—Extinguishes anxiety as a conditioned response by exposing a patient to a large amount of the stimulus he or she finds undesirable. Response prevention—The individual who would reduce anxiety by performing a ritual is not permitted to perform the ritual. Thought stopping—This technique calls for the patient to shout “STOP” or snap a rubber band on the wrist whenever an obsessive thought begins. This helps the patient dismiss the thought. Evaluation Identified outcomes serve as a basis for evaluation. In general, evaluation will focus on whether or not there is reduced anxiety, recognition of symptoms as anxiety-related, reduced incidence of symptoms, performance of self-care activities, maintenance of satisfying interpersonal relationships, assumption of usual roles, and use of adaptive coping strategies. Instructor Manual for Varcaroliss Canadian Psychiatric Mental Health Nursing Margaret J. Halter, Cheryl L. Pollard, Susan L. Ray, Mary Haase, Sonya Jakubec, Elizabeth M. Varcarolis 9781926648330, 9781771721400