Psychiatric Nursing

Definition

Therapeutic nurse-patient relationship is a mutual learning experience and a corrective emotional experience for the patient. It is based on the underlying humanity of nurse and patient, with mutual respect and acceptance of ethnocultural differences.

Peplau's theory

Peplau's theory focuses on the interpersonal processes and therapeutic relationship that develops between the nurse and client. The interpersonal focus of Peplau's theory requires that the nurse attend to the interpersonal processes that occur between the nurse and client. Interpersonal process is maturing force for personality. Interpersonal processes include the nurse- client relationship, communication, pattern integration and the roles of the nurse. Psychodynamic nursing is being able to understand one's own behavior to help others identify felt difficulties and to apply principles of human relations to the problems that arise at all levels of experience. This theory stressed the importance of nurses' ability to understand own behavior to help others identify perceived difficulties.

1. Orientation:

During this phase, the individual has a felt need and seeks professional assistance. The nurse helps the individual to recognize and understand his/ her problem and determine the need for help.

2. Identification

The patient identifies with those who can help him/ her. The nurse permits exploration of feelings to aid the patient in undergoing illness as an experience that reorients feelings and strengthens positive forces in the personality and provides needed satisfaction.

3. Exploitation

During this phase, the patient attempts to derive full value from what he/ she are offered through the relationship. The nurse can project new goals to be achieved through personal effort and power shifts from the nurse to the patient as the patient delays gratification to achieve the newly formed goals.

4. Resolution

The patient gradually puts aside old goals and adopts new goals. This is a process in which the patient frees himself from identification with the nurse.

Overlapping phases in nurse- patient relationship

Peplau defines Nursing Process as a deliberate intellectual activity that guides the professional practice of nursing in providing care in an orderly, systematic manner.

Peplau explains 4 phases such as:

• Orientation: Nurse and patient come together as strangers; meeting initiated by patient who expresses a "felt need"; work together to recognize, clarify and define facts related to need.

• Identification: Patient participates in goal setting; has feeling of belonging and selectively responds to those who can meet his or her needs.

• Exploitation: Patient actively seeks and draws knowledge and expertise of those who can help.

• Resolution: Occurs after other phases are completed successfully. This leads to termination of the relationship.

In Nursing Process, the orientation phase parallels with assessment phase where both the patient and nurse are strangers; meeting initiated by patient who expresses a felt need. Conjointly, the nurse and patient work together, clarifies and gathers important information. Based on this assessment the nursing diagnoses are formulated, outcome and goal set. The interventions are planned, carried out and evaluation done based on mutually established expected behaviours.

Goals of Nurse-Patient Relationship

Goals of nurse-patient relationship as given by Travel bee Joycee in 'Intervention in Psychiatric Nursing'

1.       The nurse helps the patient to cope with the present problems.

o   The reasons for patient's hospitalization

o   Identify patient's perception of present problems

o   Collection of information from the patient himself.

o   Nurse does not try to go back to the past history from secondary sources.

2.       The nurse helps the patient to understand the problems.

o   Nurse keeps this goal through out the relationship.

3.       The nurse helps the patient to understand his active participation in an experience.

4.       The nurse assists the patient to identify emerging problems realistically.

5.       The nurse helps the patient to find out a new alternative for his or her problem.

6.       The nurse helps the patient to try out new patterns of behaviour.

7.       The nurse helps the patient to communicate.

8.       The nurse helps the patient to communicate.

9.       The nurse helps the patient to find meaning in his illness.

Types of Therapeutic relationship

Based on the goals it can be divided in to:

1.       Immediate: in this situation, the nurse and client do not know each other and the client is in immediate severe difficulty that requires the nurse to interact or intervene.

2.       Short-term: The nurse and the patient have an association with each other. Even if the nurse knows the patient, she has no responsibilities for the patient.

3.       Long-term: Nurse interacts with the patient in an effort to provide a corrective emotional experience. The nurse will be supporting the patient and giving care to the patient.

Components of nurse-patient relationship

The components of the nurse-client relationship, rapport, power, trust, respect, and intimacy, are present whenever the nurse is providing nursing services. The nurse-client relationship is therapeutic; it is based on trust, respect and intimacy with the client and requires the appropriate use of power.

1.     Rapport

Getting acquainted and establishing rapport are the primary tasks in relationship development. It implies special feelings on the part of both the client and nurse based on acceptance, warmth, friendliness, common interest, a sense of trust and a non-judgmental attitude. Establishing rapport may be accomplished by discussing non-health related topics.

2.     Power

The therapeutic nurse-client relationship is one of unequal power. Although nurses may not perceive themselves as having power in the relationship, nurses have more power than the client. The power of the nurse comes from the authority of own position in the health care system, specialized knowledge, influence with other health care providers and the client's significant others, and access to privileged information. In any professional-client relationship, there is an imbalance of power in favour of the professional, and is reinforced in health care services by the inherent vulnerability of a client needing care.

3.     Trust

To trust another, one must feel confidence in that person's experience, reliability, integrity, veracity and sincere desire to provide assistance when requested. It is the basis of therapeutic relationship. The nurse must have perfect skills that foster the development of trust-worthiness. Clients expect the nurse to have the necessary knowledge and skills and to demonstrate caring attitudes and behaviours, and so entrust their care to the nurse. Trust is critical, as the client is in a vulnerable position in the relationship. Part of trust is keeping promises to clients. If trust is breached, then it becomes very difficult to re-establish it.

4.     Respect

To show respect is to believe in the dignity and worth of an individual regardless of his or her unacceptable behaviour. Respect for the dignity and worth of the client is fundamental to the relationship. The nurse needs to know and understand the culture and other aspects of the client's individuality and to take these into account when providing care. Part of respect is being non-judgmental of the client, and seeking to discover the meaning behind certain of the client's behaviours.

The nurse can convey an attitude of respect through the following interactions:

-          Calling the person by name

-          Spending time with the individual

-          Allowing for sufficient time to answer the client questions and concerns

5.     Genuineness

The concept of genuineness refers to the nurses' ability to be open, honest and real in interactions with the client. To be 'real' is to be aware of what one is experiencing internally and express this awareness in the therapeutic relationship. When one is genuine, there will be congruence between what is felt and what is being expressed.

6.     Intimacy

Intimacy relates to the kinds of activities nurses perform for and with the client which create personal and private closeness on many levels. This does not refer to sexual intimacy. This can involve physical, emotional and spiritual elements.

Principles of nurse-patient relationship

A nurse is expected to be competent and to have the professional attributes required to manage a therapeutic relationship. The nurse-client relationship is established and maintained by the nurse through the use of professional nursing knowledge and skill, and caring attitudes and behaviours. The following are the underlying principles of professional practice:

1.        The nurse functions within the standards for nursing practice.

2.       The nurse knows the requirements of and recognizes own accountability for maintaining professional behaviour. It is the responsibility of the nurse to set and maintain the appropriate boundaries for the duration of the relationship regardless of the wishes of a client or the setting in which the relationship occurs. Nurses are responsible for the outcomes of their actions in the nurse client relationship, including outcomes that may have been unintended, but should have been foreseen.

3.       Although both the nurse and the client have needs, the therapeutic nurse-client relationship is developed for the purpose of promoting client health and well-being and not to meet the needs of the nurse.

4.       The nurse respects the individual characteristics of the client such as cultural and social identity, appearance, sexual orientation and religious affiliation, and recognizes the impact that these have on both the nurse-client relationship and the health of the client.

5.       Nurses recognize when they do not possess the necessary knowledge or skills to manage the therapeutic nurse-client relationship and seek information and assistance from other members of the health team or elsewhere.

6.       It is recognized that some client's behaviour can be abusive to nurses. It is the nurse's responsibility to understand the meaning behind the abusive behaviour and to work with the health team to develop strategies to meet the client's needs. The nurse seeks help and guidance when dealing with challenging clients.

Structuring Therapeutic Relationships

Central to the establishment of the therapeutic nurse-client relationship is the nurse's ability to use a wide range of communication strategies and effective interpersonal skills. Effective communication is an essential factor in creating and maintaining a successful relationship. Regardless of the setting and the length of interaction, the nurse acts in therapeutic ways to manage the boundaries of the relationship. This involves:

• introducing self to the client and addressing the client by preferred name and/or title;

• listening to the client without immediately giving advice or diminishing the client's feelings (The nurse listens to, understands and respects the client's values, opinions, needs, and ethno-cultural beliefs. These latter elements are integrated into the care plan, with the client's assistance. The nurse listens to the concerns of the family and significant others about the client and acts on those concerns as appropriate.);

• identifying the goals and wishes of the client and incorporating them into the plan of care;

• giving the client time and opportunity to explain self and to ask questions;

• exploring unusual comments, attitudes or behaviours of clients to discover the underlying meaning;

• showing a genuine interest in, and compassion for, the client;

• providing information to promote client choice and to enable the client to make informed decisions;

• helping clients find the best possible solution for themselves, given their personal values, beliefs, and different decision making styles (The nurse discusses the client's beliefs and wishes with them and encourages them to advocate on their own behalf or advocates for them.); and

• discussing the boundaries of confidentiality with the client including the nurse's legal responsibilities.

STAGES OF NURSE-PATIENT RELATIONSHIP

A.   Pre-interaction Phase

Pre-interaction phase begins before the nurse's first contact with the patient. Nurse's initial task is one of self exploration. In the first experience working with psychiatric patients, the nurse brings misconceptions and prejudices of the general public, in addition to feelings and fear about new situations.

Common Concerns of Psychiatric Nursing students are:

1.       afraid of being rejected by the patient

2.       anxiety due to the newness of the experience

3.       concerned about over identifying with the patient

4.       doubtful about the effectiveness of the skills or coping activity

5.       fearful of physical danger/violence

6.       suspiciousness of psychiatric patients behaviours

7.       uncertain about ability to make unique contribution

8.       vulnerable to emotionally painful experiences

9.       worried about hurting the patient psychologically

Tasks in Pre interaction phase

• obtaining available information about the patient from medical records, significant others or other health team members

• initial assessment form the available information

• explore own feelings, fantasies and feelings

• analyse professional strengths and limitations

• plan for first meeting with patient

B.   Introductory phase

During this phase the nurse and patient fist meet. One of the first primary concerns of the nurse at this phase is to find out why the patient sought help. The reasons for seeking help and whether or not it was voluntary from the basis of assessment help the nurse to focus on the patient's troubles and determine the patient's motivation for treatment.

Tasks in Introductory phase

• creating an environment for the establishment of trust and rapport

• determine why patient sought help

• determining a contract fro interventions that has details of expectations and responsibilities of both nurse and patient

• getting assessment information to build a strong patient database

• formulating nursing diagnosis, setting goals that are mutually agreeable to the nurse and patient

• developing a plan of action that is realistic for meeting the established goals

• explaining the feelings of both the patient and nurse in terms of the introductory phase

• analyze why patient is seeking psychiatric help:

  • desire for environmental change to treatment setting

  • control of psychiatric symptoms

  • for problem-solving

  • may be advised to seek medical help

The reason for seeking helps form the basis of the nursing assessment and helps the nurse in the patient's problems.

Formulating a contract

Tasks in this phase of the relationship are to establish a climate of trust, understanding and communication and formulate a contrast with the patient.  Elements of nurse-patient contract are:

• name of the individuals

• roles of nurse and patient

• responsibilities of nurse and patient

• expectations of nurse and patient

• purpose of the relationship

• meeting location and time

• conditions for termination

• confidentiality

Exploring the feelings

Both the nurse and patient may experience some degree of discomfort and nervousness in the introductory phase. The nurse may be well aware of thoughts and feelings.

1. Risk for Suicide related underlying psychopathology

Risk Factors

o   Suicidal ideas, feelings, ideation, plans, gestures, or attempts

o   Lack of future orientation

o   Feelings of worthlessness, hopelessness, or despair

o   Sleep disturbance

o   Substance use

o   Social isolation

o   Problems of depression

• Expected Outcomes

  • Patient remain free from harm and suicidal thoughts

• Interventions

  • Collect detailed information about the condition and related depressive thoughts

  • Assess the client's suicidal potential, and evaluate the level of suicide precautions at least daily

  • Ask the client if he or she has a plan for suicide. Attempt to ascertain how detailed and feasible the plan is.

  • Determine the appropriate level of suicide precautions for the client.

  • Help the client to identify negative thoughts and positive thoughts

  • Maintain especially close supervision of the client at any time there is a decrease in the number of staff, the amount of structure, or the level of stimulation

  • Observe, record, and report any changes in the client's mood

2. Disturbed Sensory Perception :Auditory related to biochemical changes in the brain as evidenced verbal expression of hearing voices

• Assessment Data

  • Hallucinations (auditory)

  • Inability to discriminate between real and unreal perceptions

  • Attention deficits

  • Inability to make decisions

  • Feelings of insecurity

• Expected Outcomes

  • Demonstrate decreased hallucinations

  • Interact with others in the external environment

  • Participate in the real environment

• Interventions

  • Avoid conveying to the client the belief that hallucinations are real.

  • Explore the content of the client's hallucinations during the initial assessment to determine what kind of stimuli the client is receiving, but do not reinforce the hallucinations as real.

  • Use concrete, specific verbal communication with the client.

  • Encourage the client to tell staff members about hallucinations.

  • If the client appears to be hallucinating, attempt to engage the client's in conversation or a concrete activity.

  • Show acceptance of the client's behavior and of the client as a person; do not joke about or judge the client's behavior.

3. Social Isolation

• Assessment Data

  • Inappropriate or inadequate emotional responses

  • Poor interpersonal relationships

  • Feeling threatened in social situations

• Expected Outcomes

  • Report increased feelings of self-worth

  • Identify strengths and assets

  • Engage in social interaction

• Interventions

  • Teach the client social skills. Describe and demonstrate specific skills, such as eye contact, attentive listening, and so forth.

  • Discuss the type of topics that are appropriate for casual social conversation, such as the weather, local events, and so forth.

  • Support any successes or responsibilities fulfilled, projects, interactions with staff members and other clients, and so forth.

4. Noncompliance

• Assessment Data

  • Exacerbation of symptoms

  • Failure to keep appointments

• Expected Outcomes

  • Identify risks of noncompliance Verbalize acceptance of illness

  • Identify risks of noncompliance

• Interventions

  • Teach the patient and the family or significant others about the patient's illness, treatment plan, medications

  • Help the patient to draw a connection between noncompliance and the exacerbation of symptoms.

  • If the patient expresses feelings of being stigmatized (ie, being observed taking medications by friends or coworkers), assist the patient to arrange dosage schedules so that he or she can take medications unobserved.

  • If the patient is experiencing distressing side effects, encourage him or her to report them rather than stopping medication entirely.

C.   Working Phase

The focus of working phase is to achieve the goals that were worked out in the nurse-patient contract. This is the time for working on solving the problems and trying out new behaviours. Most of the therapeutic work is carried out during this phase of relationship. The nurse and the patient explore stressors and promote the development of insight in the patient by6 linking perceptions and thoughts feelings and actions.

Tasks in working phase

• Maintaining the trust and support that was established during the orientation phase of relationship

• Promoting the patient's insight and perceptions of reality

• Problem solving using the model presented earlier

• Overcoming resistant behaviour on the part of the patient as the level of anxiety rises in response to discussion of painful incidents.

Working phase consists of periods of growth and resistance. As the relationship moving towards its goals, the client's behaviour changes. At this time, it is important to explore the meaning of the change in the client. Patients often display resistance during this phase, because it involves greater part of the problem-solving process. As the relationship develops, the patient begins to feel close to the nurse and responds by changing the old defenses and resisting the nurses attempt to move forward. This results in impasse or plateau in the relationship.

Therapeutic Impasses

For variety of reasons therapeutic communication can be hindered. Therapeutic impasses are blocks in the progress of nurse-patient relationship. They arise for variety of reasons, but the all crates stall in the process of nurse-patient relationship.  Impasse provokes variety of emotions in both he patient and nurse ranging from anxiety and apprehension to frustration, love, or intense anger. The commonest four impasses are discussed here: resistance, transference, counter transference and boundary violations.

Resistance

Resistance is the patent's reluctance or avoidance of verbalizing or experiencing troubling aspects of oneself. The term was first coined by Freud. Resistance is often caused by patient's unwillingness to change when the need for change is recognized. Patient usually displays resistance during the working phase of nurse-patient relationship, because greater part of problem-solving occurs during this phase.

Transference

Transference is an unconscious response in which the patient experiences feelings and attitudes toward the nurse that were originally associated with other significant figures I his or her life.

• They may be triggered by superficial similarity, such as facial features or speech, or by personality style or trait.

• These reactions are the patient's attempt to reduce anxiety.

• The nurse may be viewed as an authority figure from the past such as parent figure, or lost loved object, such as former spouse

• Transference reactions are harmful to the therapeutic relationship only if they are ignored and unexplained.

Countertransferance

It is a therapeutic impasse created by the nurse's specific emotional response to the qualities of the patient. This is inappropriate to the content and context of therapeutic nurse-patient relationship. It is transference applied to the nurse. It is natural that nurse feels warmth toward or liking for some patients more than others. The nurse also will be genuinely angry about the actions of some patient. But in countertransfernce, the nurse's responses are not justified by reality. Here nurse identify the patient with individuals from their past, and personal needs interfere with their therapeutic relationship.

Boundary Violations

Here the nurse goes beyond the boundaries of therapeutic relationship and establishes a social, economic, or personal relationship with a patient. Boundary violation is involved whenever a nurse is doing or thinking of doing something special, different or unusual for a patient.

D.   Termination of Relationship

At the beginning of the relationship, the nurse establishes with the client, family and health team an estimated period of time that the relationship will last. The health-related goals and needs of the client determine when the relationship will end. The nurse might indicate, for example, the necessity of providing care for one shift in a hospital setting or until the ulcer heals (at home in the  community), or until the client has no further need for nursing services.

As the time for terminating the relationship approaches, the nurse needs to discuss ongoing plans for meeting the client's care needs. The nurse and client may identify other necessary resources with other team members helping the client identify what would work best for him/her. In some settings, this may include discharge planning with a referral to community organizations. It may also involve a transfer to another health care provider in the same organization or from one shift to another.

Conclusion

All nurses need to work together to prevent abuse of clients and ensure safe, effective care.

Each nurse needs to:

• understand the nature of the therapeutic nurse-client relationship;

• establish and maintain the boundaries of the relationship;

• ensure that the client understands the role of the nurse and the limits of that role;

• be aware of situations that are high risk for boundary violation, for example, settings where nurse client relationships are long term or for settings where the nurse works with little supervision;

• terminate the relationship with the client in a manner that reflects an understanding of the client's needs and goals;

• practice self-reflection to achieve awareness of own professional practice and to understand the dynamics of client situations;

• ensure own personal needs are met outside client situations;

• take action to deal with personal and job-related stress;

• seek out and use resources to assist in caring for clients with challenging behaviours;

• advocate for appropriate care resources for clients;

• intervene when witnessing abuse of clients or colleagues crossing the boundaries;

• report incidents of crossing boundaries, professional misconduct and abuse in the appropriate manner; and

• advocate for the elements of a quality practice setting.

References

1. Dexter G. Psychiatric Nursing skills- A patient-Centred approach. 2^nd edn. Chapmal & Hall London. 1995.

2. Fertinash M K. & Hooldey A P. Psychiatric Mental Health Nursing. 3^rd edn. Mosbey Philadelphia, 2003.

3. Teyler MC. Eessentials of Psychiatric Nursing. 14^th edn. Mosbey London, 1994.

4. Stuart GW. Principles and Practice of Psychiatric Nursing. Harcourt Health Sciences, 2006.

5. Mohr KW. Psychiatric Mental Health Nursing 6^th edn. LWW Philadelphia, 2006.

6. Standard For The Therapeutic Nurse-Client Relationship. Nurses Association Of New Brunswick, Canada, 2000.

 

 

INTRODUCTION

Insomnia is a significant health care problem. It can create daytime fatigue, impaired social or occupational functioning, and reduced quality of life. Treating the secondary cause of insomnia may alleviate the sleep difficulty without the need to use sedative -hypnotic agents.

INDICATIONS

Sedative-hypnotics are used in the short term management of various anxiety states and to treat insomnia. Selected agents are used as anticonvulsants and preoperative sedatives. (Phenobarbital, secobarbital and pentobarbital) and to reduce anxiety associated with drug withdrawal (chloral hydrate).

ACTION

It causes generalized CNS depression. They may produce tolerance with chronic use and have the potential for psychological or physical dependence.

CLASSIFICATION

Chemical class	Generic name	Daily dose(mg)	Half life( hour)
Barbiturates	Amo barbital Butabarbital Mephobarbital Pentobarbital Phenobarbital secobarbital	60-200 45-120 32-200 60-100 30-200 100-200	16-40 66-140 11-67 15-50 53-118 15-40
Benzodiazepines	Estrazolam Flurazepam Quazepam Temazepam Triazolam	1-2 15-30 7.5-15 15-30 0.125-0.5	8-28 2-3 41 9-15 1.5-5.5
Miccelaneous	Chloral hydrate Eszopiclone Zalpilon zolpidem	500-1000 1-3 5-20 5-10	8-10 6 0.5-1.5 1.4-4

CONTRAINDICATION/ PRECAUTIONS

Sedative hypnotics are contraindicated in individuals with hypersensitivity to the drug or to any drug within the chemical class.

Caution should be used in administering thses drugs or clients with hepatic dysfunction or severe renal impairment. They should be used with caution in clients who may be suicidal or who may have been addicted to drugs previously. Hypnotic use should be short term. Elderly clients are more sensitive to CNS depressant effects , and dodge reduction may be required.

INTERACTIONS

Addictive CNS depression can occur when sedative-hypnotics are taken concomitantly with alcohol, antihistamines , antidepressants, phenothiazines,  or any other CNS depressants . Barbiturate induces hepatic drug-metabolizing enzymes  and can increase the effectiveness of drugs metabolized  by the liver. Sedative hypnotics should not be used with MAOIs.

Disadvantage of barbiturates

Barbiturates    and other older sedative hypnotic agents (alcohol,meprobamate,chloral hydrate) have many disadvantage that have led their greatly decreased use. It include the following

• Tolerance develops to their ant anxiety and sedative effects.
• They are very addictive.
• They cause serious even lethal ,withdrawal reactions
• They are dangerous in case of overdose.
• They cause CNS depression.
• They cause a variety of drug interactions, particularly when mixed with CNS depressants such as alcohol.

POSSIBLE NURSING DIAGNOSIS

1. Risk for injury related to abrupt withdrawal from long term use or decreased mental alertness caused by residual sedation.
2. Disturbed sleep pattern related to situational crises, physical condition or severe level of anxiety.
3. Risk for activity intolerance related to side effects of lethargy, drowsiness, and dizziness.
4. Risk for acute confusion related to action of the medication on the CNS.

CONCLUSION

Psychotropic medications are intended to be used as adjunctive therapy to individuals or group psychotherapy. Ant anxiety agents and sedative-hypnotics are CNS depressants and have a potential for physical and psychological dependence. Addiction and side effects are common to these drugs. So teaching has to be given regarding this.

INTRODUCTION

There has been exponential increase in the number of medications demonstrated to be effective for the treatment of anxiety and anxiety disorders. Beginning in the late 19 the century, there was a progression from alcohol, bromides and opiates to barbiturates developed in the early 20^th century. Barbiturates were effective in decreasing anxiety, but they were addictive in and lethal in overdose.  There was  continued advancement in the development of anxiolytics like meprobmate and the antihistamine hydroxyzine. The major advancement in the field of anxiolytics  in the 1960 s was the development and approval of  benzodiazepines. Also there was a cascade of anxiolytic research in the 1990 s.

INDICATION

Anti anxiety drugs are also called anxiolytcs and minor tranquilizers.  They are used in the treatment of anxiety disorders, anxiety symptom, acute alcohol withdrawal, skeletal muscle spasms, convulsive disorders, status epileptics and preoperative sedation. Their use and efficacy for periods greater than 4 months have not been evaluated.

ACTION

Anti anxiety drugs depress the sub cortical levels of CNS, particularly the limbic system and reticular formation. They may potentiate the effect of powerful inhibitory neurotransmitter GABA in the brain thereby producing a calming effect. All levels of CNS depression can be affected ,from mild sedation to hypnosis to coma .

EXCEPTION

Buspirone  does not depress the CNS .Although its action is unknown , the drug is believed to produce the desired effects through interactions with serotonin, dopamine, and other neurotransmitter receptors.

CLASSIFICATION

1. Barbiturates.

Barbiturates can be divided into 4 main groups.

a)  Long acting; Duration of action is more than 8 hours. Eg. Phenobarbital.

b) Intermediate acting- duration of action is 5-8 hours. Eg; amobarbital and pentobarbital.

c)Short acting- duration of action is 1-5 hours.  Eg; secobarbital .

d)Ultra short acting- duration of action is less than 1 hour. eg: thiopentone and methohexital.

The barbiturates are no longer used commonly as anti-anxiety agents. They produce multiple side effects like excessive sedation, respiratory and circulatory depression, hepatic enzyme induction, dependence, withdrawal symptoms, rebound increase in REM sleep on withdrawal, and potential for use in suicide.

2. Non-barbiturate , nonbenzodiazepine antianxiety agents

these  can  be further divided into following categories.

A)  Carbamates-not  used commonly because of potentials of abuse  and dependence. Eg: meprobamate, tybamate and carisoprodol.

B)  Piperidinediones- this too use  not used now due to dependence potential. Eg; gluethimide.

C) Alcohols- these drugs are highly dependence producing . eg: ethanol, chloral hydrate, and ethchlorvynol.

D) Quinazoline derivatives- eg;methaqualone. It had become a street drug or drug of abuse . So it was discontinued as an ant anxiety agent and a hypnotic.

E)  Anti-Histaminics- eg; diphenhydramine , hydroxycine , and promethazine. Diphenhydramine is usually combined with methaqualone or diazepam .

They may be used as hypnotic-sedative , but their use as  antianxiety agent is minimal and probably not effective.

F)   Cyclic ethers- Not used commonly as it is very effective and is dependency producing.

G) Others- antipsychotic (eg; thioridazine) and antidepressants (eg: doxepine) are sometimes used for  treatment of severe intractable  anxiety.  However they are not the drugs of first choice and should be used with discretion, when all other rugs have failed to benefit.

H) Beta blockers- eg: propanolol.  This is particularly  effective in treatment of peripheral somatic manifestations of anxiety.  It is also used as the drug of first choice of anticipatory anxiety and situational anxiety.

Propanolol can be used either alone or along with benzidiazepines. The role of this in the treatment of psychic manifestations of anxiety is still in research. It is contraindicated in patients of bronchial asthma and cardiac conditions.

3) Benzodiazepines

Since the discovery of chlordiazeopoxide in 1957 by Sternbach, benzodiazepines have replaced other anti-anxiety drugs.  Presently benzodiazepines are the drugs of first choice in treatment of anxiety and for the treatment of insomnia.

The benzodiazepines are thought to reduce anxiety because they are powerful potentiators (receptor agonists) of the inhibitory neurotransmitter GABA. A   post synaptic receptor site specific   for the benzodiazepine molecule is located next to GABA receptor.  The BZ molecule and GABA bind to each other at the GABA receptor site. The result is an enhancement of the actions of GABA, resulting in an inhibition of neurotransmission (a decrease in the firing rate of neurons), resulting in a clinical decrease in the person's level of anxiety.

The benzodiazepines are classified according to their elimination half lives.

Class and drug	Elimination half live	Usual hypnotic dose	Oral dose
1.Very short acting Triazolam Midazolam	2-5 2-5	.125-.25 ____	__­­­­­­­­­­­­­­­­­­­­­­­
2.Short acting oxazepam lorazepam temazepam alprazolam   estazolam	5-15 10-20 10-20 6-20   8-24	15-30 0.5-2 15-30 not used   1-2	15-120 2-6 15-30   0.5-6 1-2
3. Long acting chlordiazepoxide diazepam flurazepam chlorazepate nitrazepam prazepam halazepam clonazepam quazepam	25-48 14-90 30-100 30-100 20-60 30-60 30-60 20-40 40-160	10-25 2-10 15-30 7.5-30 5-10 10-20 20-40   7.5-30	15-100 2-60 15-60 7.5-60 5-20 20-60 40-160 0.5-20 7.5-15

INDICATIONS

The indications for the use oef benzodiazepines are as follows.

1. Generalized anxiety disorder, adjustment disorder with anxious mood.

2. Panic disorder, agoraphobia, and school phobia (particularly alprazolam and clonazepam)

3. Agitated depression, (added to antidepressants for first 1-2 week); alprazolam probably has an antidepressant effect.

4. Insomnia

5. Stage 4 NREM sleep disorders like enuresis, somnambulism, (diazepam reduces duration of stage 4 NREM sleep).

6. Nightmares (diazepam also reduces REM sleep duration)

.7.Premedication in anaesthesia (intravenous lorazepam, midazolam or diazepam).

8. Anticonvulsant use (drugs of choice for status epilepticus, myoclonic seizures, and certain infantile spasms).

9.To produce skeletal muscle relaxation ( eg: in tetanus, cerebral palsy)

10. Treatment of alcohol and other drug withdrawal syndromes.

11. for minor surgical, endoscopic or obstetric procedures.

12. Acute mania (clonazepam, either alone or with lithium)

13. Antipsychotic induced akathisia

14.Emergency management of acute psychoses ( iv lorazepam , along with parenteral antipsychotics)

15. Narcoanalysis or abreaction (IV diazepam)

16. Treatment resistant schizophrenia (experimental use in

High doses)

17. Psychosomatic disorders

Whenever administered, benzodiazepines should not be ordinarily used for more than 6 weeks at one time. Otherwise the risk of dependence is high, and tolerance occurs.

MECHANISM OF ACTION

Exact mechanism of action of benzodiazepines is not clear. The recent discovery (1977) of benzodiazepine receptors has shed some light on the mode of action.

There are presently 2 known benzodiazepine receptors.

• BDZ receptor 1, which is linked with GABA ( Gamma -Amino Butyric - Acid)
• BDZ receptor 2, which is alone and is probably involved in cognition and motor control.

Thus benzodiazepines probably act by enhancing GABA transmission in brain.

Benzodiazepine receptor antagonists (eg:  flumazenil) are anxiety provoking agents. The benzodiazepines have no significant clinical advantage over each other, although differences in half life can be clinically useful.  For eg; patients with persistent high level of anxiety should take a drug with a long half life. Patients with fluctuating anxiety might do better with either a short acting drug or drug with a  sustained release formulation ( alprazolam,  chlorazepate , diazepam and adinazolam ) . Sustained release BZP  blunt the peaks  of toxicity   and the troughs of symptom  breakthrough and are becoming a popular alternative  to the original formulations .

In addition the lipid solubility of each BBZP determines the rapidity of onset and the intensity of effect, and this should be considered when selecting a BZP. FOR eg; the diazepam is more lipid soluble than lorazepam , thus is more readily move into and out of  the central nervous system (CNS) .and is more extensively distributed toperipheral sites particularly  to fat cells.

The rate of absorption of different BZP from the gastrointestinal tract varies considerably, thus affecting this rapidity and intensity of onset of their acute effects. Antacids and food in the stomach slow down this process when these drugs are taken by mouth.

The injectable BZP (lorazepam, and midazolam) have been proven reliable when administered in the deltoid muscle. Diazepam results in predictable and rapid rises in the blood level  when used intravenously . Concentrations of BZP in the blood have not been firmly correlated to clinical effects, so blood level measurements are not clinically helpful.

Some patients need to take anti anxiety drugs for extended periods. Because of the potential disadvantage of BZP, they should be always used along with nonpharmacological treatments for the patient with chronic anxiety   or insomnia. Psychotherapy, behavioural technique, environmental changes, stress management, sleep hygiene, and an ongoing therapeutic relationship continue to be important in the treatment of anxiety disorders and insomnia.

In general the treatment of BZP should be brief and used during a time of specific stress or for a specific indication. The patient should be observed frequently during the early days of treatment to assess target symptom response and monitor side effects so that the dose can be adjusted as needed. Some patients, such as those with [panic disorder, may require daily dosing and long term BZP treatment.

SIDE EFFECTS

The side effects are common, dose related, usually short term and almost always harmless. It include nausea, vomiting , weakness , epigastric pain , diarrhoea, vertigo, blurring of vision , body aches , urinary incontinence( rare), impotence., lassitude, sedation, increased reaction time ,ataxia ( in high doses ) , dry mouth retrograde amnesia ( rare) , impairment of driving skills , severe effects  when administered with alcohol,  irritability ( particularly with flurazepam and (chlordiazepoxide) , disinhibited behaviour ( particularly with diazepam ) .

Tolerance can develop  to the sedative effect of BZP  which in some ways is an advantage , but is unclear whether  tolerance also develop to induced sleep or antianxiety effects. These drugs should be tapered to minimize withdrawal symptoms and rebound symptoms of insomnia and antianxiety. If these symptoms occur the dose should be   raised until symptoms are gone and then tapering is resumed at a slower rate.

Withdrawal syndromes include agitation, anorexia, anxiety, autonomic arousal, dizziness, generalized seizures, hallucinations, headache, hyperactivity, insomnia, irritability, nausea and vomiting, sensitivity to light and sounds, tinnitus and tremulousness.

Elderly patients are more vulnerable to side effects because the aging brain is more sensitive to sedatives, Dosing ranges from one-half to one-third of the usual daily dose used for adults.  The BZP with no active metabolites are less affected by liver disease, the age of the patient, or drug interactions.

BZP are more successfully used in children to treat sleep waking ,in single dose to allay anticipatory anxiety , and to  treat panic , generalized anxiety disorder , and avoidant personality disorder  but in general they can increase anxiety  and produce or aggravate behaviour disorders ,especially ADHD.

BZP during pregnancy have been associated rarely with   palate malformations and intrauterine growth retardations especially when used during the first trimester.  When used in late trimester or during breast feeding, these drugs are associated with floppy infant syndrome, neonatal withdrawal symptoms and poor sucking reflex. Hence they are not recommended.

4. Newer drugs

a) Buspirone

Buspirone is a new anti-anxiety drug which is not a BZP. It is an azaspirodecane -Dione (azaspirone) derivative and is 5 HT partial agonist and is a selective DA autoreceptor antagonist. It also inhibits the spontaneous firing of 5HT neurons. It does not seem to act upon BZPreceptors. It is anxioselective with no sedative action, no anticonvulsant or muscle relaxant properties.

It is administered in a dose of 15-30 mg/day, in a thrice a daily schedule due to short half life. As it has a slower and more gradual onset of action, it usually takes about 2 weeks before the anti-anxiety effects of buspirone are evident .It is not useful in the treatment of panic disorder. The side effect includes dizziness, headache, light headedness and diarrhea.

As it is anxioselective, and lack any risk of dependence, it may replace the BZP as the drug of choice in GAD.

B) Zopiclone

Zopiclone belongs to a new class of    BZP drugs , the cyclopyrrolones. Cyclopyrrolone derivatives also act on the GABA receptors, but at   a site distinct from that of BZP.

Zopiclone has a short duration of action as well as shorter onset. After oral administration it is observed rapidly, with peak plasma  concentration occurring in about 60 minute. The elimination half life is 4-6 hours.

The usual dose of zopiclone is 3.75-7.5 mg at bedtime ( lower dose in elderly and in patients with severe hepatic failure) . The side effects include bitter taste, dry mouth, drowsiness, nausea and headache. Its safety in pregnancy, lactation and in children are not proven. It is clinically superior to BZP in subjective awakening quality, well being and attention  span in the morning.

3) Zopidem

It is an imidazopyridine    derivative which I being marketed as a hypnotic. It is administered in a dose of 5-10 mg for hypnotic use. It has a half life of 2-3 hours; therefore it is useful in the treatment of difficulty in initiation of sleep.

The side effects include drowsiness, dizziness, headache, depression, nausea, dry mouth and myalgia.It should not be used for more than 2 weeks at one time. Its   safety in pregnancy, lactation and children is not proven.

4) Zalpelon

Zalpelon is an pyrazylo-pyramidine derivative which is being marketed as a hypnotic. Although  a non BZP  drug it acts on  the omega -1 BZP  receptor located on the alpha sub unit of the GABA -A receptor complex ( causing sedation ) , with very little effect on omega 2 and omega 3 receptors.

Side effects include headache, drowsiness, dizziness  nausea and myalgia . It should not be used for more than 1 week at a time .Its safety in pregnancy, children and lactation are not proven.

POSSIBLE NURSING DIAGNOSIS

1. Risk for injury related to seizures; panic anxiety, abrupt withdrawal after long term use, effects of intoxication and overdose.
2. Risk for activity intolerance related to side effects of sedation and lethargy.
3. Risk for acute confusion related to action of the medication on CNS.

BIBLIOGRAPHY

Books

1. Gail W Stuart , Michele T Laraia. Principles and practice of Psychiatric Nursing .8^th edn. Missouri. Mosby publications. 2005.
2. Mary C Townsend. Psychiatric Mental Health Nursing . 5^th edn. Philadelphia. FA D avis company.
3. Cacelia  Monat Taylor. Essentials of Psychiatric Nursing .5^th edn. Missouri. Mosby publications . 2002
4. Niraj Ahuja. A Short Textbook of Psychiatry.5^th edn. New Delhi.Jaypee publications .2002.
5. Deborah Antai Otong.Psychiatric Nursing. Biological and Behavioural Concepts.U.S.  North Texas Health Care System. 2003.

Journals

1. Paul PD. Trends  in the Pharmacologic Management of Insomnia.J Clin Psychiatry 2006; 67: suppl 13: 5-8.
2. Milton KE. Influence of Pharmacokinetic  profiles on safety and efficacy of Hypnotic medications.J of Clin Psychiatry. 2006; 67: suppl 13: 9-12.

 

Outline

Introduction

Definition & Description

Epidemiology

Aetiology

Classification

Clinical features and Diagnosis (ICD-10)

Management

Nursing Process

Conclusion

References

Introduction

"Phobias are irrational fears of a specific object, situation or activity, often leading to persistence avoidance of the feared object, situation or activity."

In an effort to reduce the intense anxiety attached to phobic objects and situations, patients do their best to avoid the feared stimuli. Thus, phobias consist both of the fears and the avoidance components.

The common types of phobias are of three categories:

(1) agoraphobia

(2) specific phobia, and

(3) social phobia- two subtypes, nongeneralized type (a fear of public situations such as public speaking or performing on stage) and a generalized type (almost all social interactions are feared)

Definition & Description

Agoraphobia

"Agoraphobia is defined as a fear and avoidance of being in places or situations from which escape might be difficult or in which help might not be available in the event of sudden incapacitation."

As a result of such fears, the agoraphobic person avoids travel outside the home or requires accompaniment when away from home.

• It is characterised by an irrational fear of being in places away from the familiar setting at home.
• It includes fear of open spaces, public places, crowded places, and any other places where there is no escape to a safe place.
• A full blown panic attack may occur (agoraphobia with panic disorder) or a few symptoms like dizziness or tachycardia may occur (agoraphobia without panic disorder).
• As symptoms worsen, there is a gradual restriction of normal day-to-day activities, and even person confines to home, often depend on a person to go outside(phobic companion).

Social phobia

"The central feature of social phobia is a persistent, irrational fear of activities or social interactions, characterised by fear of performing activities in the presence of other people or interacting with others."

• Common social phobias involve fears of speaking or eating in public, urinating in public lavatories, writing in front of others, or saying foolish things in social situations.
• Many individuals with social phobia are self-critical and perfectionistic-attempting to conduct themselves according to extreme and exacting standards to avoid the negative evaluation of others that they may perceive as epidemic.
• By leaving anxiety-provoking situations (escape) them entirely (avoidance), individuals with social phobia may reduce or prevent the immediate experience of anxiety, but this relief may also reinforce their belief in their inadequacies.
• Individuals with social phobia experience significant impairment in social, educational, and vocational functioning.
• They may find it difficult to initiate or maintain social or romantic relationships, avoid classes that require public presentations, discontinue their education prematurely, or take jobs below their ability to avoid social or performance demands.
• Often individuals rarely seek treatment.

Specific Phobia

"A condition characterised marked and persistent fear that is excessive or unreasonable and is brought on "by the presence or anticipation of a specific object or situation (e.g., flying, heights, animals, receiving an injection, seeing blood)."

• The response may take the form of a situationally bound or predisposed panic attack, and the phobia causes marked distress or interferes with role functioning.

 

Some of the specific phobias (Kaplan & Saddock)

Acrophobia              Fear of heights Agoraphobia            Fear of open spaces Amathophobia Fear of dust Apiphobia                Fear of bees Astrapophobia Fear of lightning Blennophobia           Fear of slime Claustrophobia         Fear of enclosed spaces Cynophobia              Fear of dogs Decidophobia           Fear of making decisions Electrophobia           Fear of electricity Eremophobia            Fear of being alone Gamophobia            Fear of marriage Gatophobia              Fear of cats Gephyrophobia         Fear of crossing bridges Gynophobia             Fear of women Hydrophobia            Fear of water Kakorraphiophobia    Fear of failure

Katagelophobia         Fear or ridicule Keraunophobia         Fear of thunder Musophobia             Fear of mice Nyctophobia             Fear of night Ochlophobia             Fear of crowds Odynophobia            Fear of pain Ophidiophobia           Fear of snakes Pnigerophobia          Fear of smothering Pyrophobia              Fear of fire Scholionophobia        Fear of school Sciophobia               Fear of shadows Spheksophobia         Fear of wasps Technophobia           Fear of technology Thalassophobia         Fear of the ocean Triskaidekaphobia     Fear of the number 13 Tropophobia             Fear of moving or making changes

Epidemiology

• Phobias are the most common of all anxiety disorders.
• Social phobia is the most common of all phobias
• Lifetime prevalence rates of agoraphobia have been reported from a number of studies.
• Social phobia in males -11.1 and females -15.5 and a total of 13.3.
• Specific phobia occurs in 2.4 to 9.2 percent of children and adolescents, with usual onset between 5 and 13 years of age.
• Women receive diagnoses of specific phobia more often than men.
• Onset is often sudden and course usually chronic.

Aetiology

Classical conditioning theory

• This theory holds that phobias are learned through the association of negative experience with an object or situation. Responses of avoidance or escape are learned and serve to decrease the discomfort arising from conditioned stimuli. Repeated negative reinforcement of avoidance behaviour maintains the fear and makes it resistant to extinction.

Psychodynamic Theory:

• Deployment of three specific ego defense mechanisms in phobias.
  • The first of these is displacement, which involves the redirection of anxiety associated with an unconscious source to a conscious substitute that is often intrinsically harmless.
  • Projection is the second specific defense mechanism used by phobics to get the source outside of themselves and into the external world.
  • The third defense is avoidance, which is simply a systematic process of not coming into contact with the displaced and projected item that the anxiety is associated with.
  • If the item is dogs, the individual avoids dogs. The end result is that the three combined defenses may eliminate the anxiety because the unacceptable or forbidden thought is re-repressed.
• Freud's case of Little Hans is the model for the psychoanalytical understanding of phobias. Freud conceptualized Little Hans's fear of horses as resulting from unconscious Oedipal fears. Little Hans denied these fears and projected them onto horses. Accordingly, symptoms of phobia are thought to be related to unresolved unconscious conflicts. The anxiety of the conflict is experienced, but the source of the anxiety is shifted onto an unrelated and harmless object, and the real source of anxiety is kept from consciousness.

Biologic Theories

• Evidence suggests amygdala as the major mediator of the stress response, fear, and possibly also anxiety. Some evidence suggests dopaminergic, GABA and serotonrgic dysfunction in these areas may cause phobia (Kaplan & Saddock, 1999).
• Twin studies suggest that specific phobia has the lowest genetic contribution of any of the anxiety disorders.
• Phobias may have a genetic back up. For example, some individuals with blood-injection-injury phobias, which strongly clusters among biological relatives, may be genetically predisposed by vagal responses to certain stimuli.

Classification

Anxiety Disorders	Neurotic stress-related and somatoform disorders F40 Phobic anxiety disorders
300.01   Panic disorder without agoraphobia 300.21   Panic disorder with agoraphobia 300.22   Agoraphobia without history of panic disorder 300.29   Specific phobia 300.23   Social phobia	F40.0            Agoraphobia .00         Without panic disorder .01         With panic disorder F40.1           Social phobias F40.2           Specific (isolated) phobias F40.8           Other phobic anxiety disorders F40.9           Phobic anxiety disorder, unspecified

 

• In the first and second editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM), all phobias were grouped together.
• Social phobia first appeared in ICD-1012 years after its appearance in DSM-III

Diagnosis and Clinical features (ICD-10)

Agoraphobia

A. There is marked and consistently manifest fear in, or avoidance of, at least two of the following situations:

(1) crowds;    (2) public places;      (3) travelling alone;   (4) travelling away from home.

B. At least two symptoms of anxiety in the feared situation must have been present together, on at least one occasion since the onset of the disorder, and one of the symptoms must have been from items (1) to (4) listed below:

Autonomic arousal symptoms

(1) palpitations or pounding heart, or accelerated heart rate;     (2) sweating;

(3) trembling or shaking;     (4) dry mouth          (5) difficulty in breathing;

(6) feeling of choking;         (7) chest pain or discomfort;

(8) nausea or abdominal distress (e.g., churning in stomach);

Symptoms involving mental state

(9) feeling dizzy, unsteady, faint, or light-headed;

(10) feelings that objects are unreal (derealization), or that the self is distant or "not really here" (depersonalization);  (11) fear of losing control, "going crazy," or passing out;

(12) fear of dying;

General symptoms

(13) hot flushes or cold chills;        (14) numbness or tingling sensations.

C. Significant emotional distress is caused by the avoidance or by the anxiety symptoms, and the individual recognizes that these are excessive or unreasonable.

D. Symptoms are restricted to, or predominate in, the feared situations or contemplation of the feared situations.

E. Most commonly used exclusion clause. Fear or avoidance of situations (criterion A) is not the result of delusions, hallucinations, or other disorders, and is not secondary to cultural beliefs.

Social phobias

A. Either of the following must be present:

(1) marked fear of being the focus of attention, or fear of behaving in a way that will be embarrassing or humiliating;

(2) marked avoidance of being the focus of attention, or of situations in which there is fear of behaving in an embarrassing or humiliating way.

These fears are manifested in social situations, such as eating or speaking in public, encountering known individuals in public, or entering or enduring small group situations (e.g., parties, meetings, classrooms).

B. At least two symptoms of anxiety in the feared situation as defined in agoraphobia, criterion B, must have been manifest at some time since the onset of the disorder, together with at least one of the following symptoms:

(1) blushing or shaking;  (2) fear of vomiting; (3) urgency or fear of micturition or defecation.

C. Significant emotional distress is caused by the symptoms or by the avoidance, and the individual recognizes that these are excessive or unreasonable.

D. Symptoms are restricted to, or predominate in, the feared situations or contemplation of the feared situations.

E. The symptoms listed in criteria A and B are not the result of delusions, hallucinations, or other disorders and are not secondary to cultural beliefs.

Specific (isolated) phobias

A. Either of the following must be present:

(1) marked fear of a specific object or situation not included in agoraphobia or social phobia;

(2) marked avoidance of a specific object or situation not included in agoraphobia or social phobia.

• Among the most common objects and situations are animals, birds, insects, heights, thunder, flying, small enclosed spaces, the sight of blood or injury, injections, dentists, and hospitals.

B. Symptoms of anxiety in the feared situation as defined in agoraphobia, criterion B, must have been manifest at some time since the onset of the disorder.

C. Significant emotional distress is caused by the symptoms or by the avoidance, and the individual recognizes that these are excessive or unreasonable.

D. Symptoms are restricted to the feared situation or contemplation of the feared situation.

E. The symptoms listed in criteria A and B are not the result of delusions, hallucinations, or other disorders and are not secondary to cultural beliefs.

Differential Diagnosis

• Depression, schizophrenia, schizotypal personality, and schizoid personality, avoidant personality disorder, adjustment disorder

Management

Pharmacotherapy

• SSRIs are the drug of choice-Paroxetine is the most widely used. Fluoxetine and Sertraline are also effective.
• Benzodiazepines- Alprazolam (anti-phobic, anti-panict, and anti-anxiety) to reduce anticipatory anxiety.
• Drug treatments for specific phobia have consistently been shown to be less effective than behavioural treatments.
• b-Blockers reduce some symptoms of sympathetic arousal during exposure to feared stimuli. However, they fail to decrease subjective fear.
• While benzodiazepines may facilitate approach to the feared stimuli, they may also reduce the efficacy of behaviour therapies by inhibiting the experience of anxiety during exposure.
• Beta blockers-Propranolol has been found to effective in reducing autonomic symptoms associated with

Cognitive-behavioural interventions

• Combining progressive relaxation and graduated imaginal exposure to the feared stimulus, systematic desensitization has been used.
• Systematic desensitization works by the principle of reciprocal inhibition, which asserts that the sympathetic response associated with anxiety is incompatible with, and thus inhibited by, the parasympathetic response that occurs during deep muscle relaxation.

Exposure

• Prolonged and repeated in vivo exposure to feared stimuli is by far the most studied and effective form of treatment for specific phobia.
• Cognitive restructuring- Phobia-specific irrational thoughts may contribute to the development of the phobia, maintain avoidance behaviour, and contribute to physiological symptoms. Cognitive restructuring treatments help patients to monitor irrational thoughts and change underlying beliefs, so that they are better able to enter feared situations.

Nursing Process

Nursing Diagnosis: Fear (Response to perceived threat that is consciously recognized as a danger)

Assessment

 

• Anticipatory anxiety (when thinking about the phobic object)
• Panic anxiety (when confronted with the phobic object)
• Avoidance behaviors that interfere with relationships or functioning
• Recognition of the phobia as irrational
• Embarrassment over the phobic fear
• Sufficient discomfort to seek treatment

Outcomes Identification

• Verbalize feelings of fear and discomfort
• Respond to relaxation techniques with decreased anxiety
• Effectively decrease own anxiety level
• Decrease avoidance behaviours
• Demonstrate effective socio-occupational functioning
• Manage the anxiety response effectively

Nursing Interventions

• Encourage the client to express feelings, initially, without discussing the phobic situation specifically.
• Teach the client and family or significant others about phobic reactions.
• Reassure the client that he or she can learn to decrease the anxiety and gain control over the anxiety attacks.
• Reassure the client that he or she will not be forced to confront the phobic situation until prepared to do so.
• Assist the client to distinguish between the actual phobic trigger and problems related to avoidance behaviors.
• Instruct the client in progressive relaxation techniques, including deep breathing, progressive muscle relaxation, and imagining himself or herself in a quiet, peaceful place.
• Encourage the client to practice relaxation until he or she is successful.
• Explain systematic desensitization thoroughly to the client.
• Reassure the client that you will allow him or her as much time as needed at each step.
• Have the client develop a hierarchy of situations that relate to the phobia by ranking from the least anxiety‑producing to the most anxiety‑producing situation. (For example, a client with a phobia of dogs might rank situations beginning with looking at a picture of a dog, up to actually petting a dog.)
• Beginning with the least anxiety-producing situation, have the client use progressive relaxation until he or she is able to decrease the anxiety. When the client is comfortable with that situation, go to the next item on the list, and repeat the procedure.
• If the client becomes excessively anxious or begins to feel out of control, return to the former step with which the client was successful; then proceed slowly to subsequent steps.
• Give positive feedback for the client's efforts at each step. Convey the idea that he or she is succeeding at each step. Avoid equating success only with mastery of the entire process.
• As the client progresses in systematic desensitization, ask the client if his or her avoidance behaviors are decreasing.
• It may be necessary to address specific avoidance behavior(s) if any persist after the client has completed the desensitizing process.

Conclusion

Most patients with phobic disorder rely on avoidance to manage their fears and anxieties. As long as they find ways to limit their lives within the limitations imposed by phobias, they experience little, if any anxiety. When they are forced to face the phobic situation, anxiety mounts and they seek treatment. Patients with more than one phobias and presence of panic symptoms often seek treatment earlier. Multiple approaches are often combined together in the treatment of a particular patient.

References

1. Gelder M., Gath D., Mayou R., owen P. Oxford Textbook of Psychiatry. Third Edition. Oxford University Press. New delhi 2000.

1. Ahuja,N. A short Textbook of Psychiatry. 5th Edition Jaypee Brothers New Delhi 2002.

1. Videbeck, SL. Psychiatric Mental heath Nursing 2nd edition. LWW Philadelphia 2004.
2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, DSM-IV-TR. Washington, DC: 2000.
3. World Health Organization: The ICD-10 Classification of Mental and Behavioural Disorders: Diagnostic Criteria for Research. World Health Organization, Geneva, 1993.
4. Freud, S. Analysis of a phobia in a five-year-old boy. In Standard edition of the complete psychological works of Sigmund Freud, Vol. 10 (ed. J. Strachey), pp. 5-149. Hogarth Press, London 1909.

Prepared by: Mr. Binil V, Lecturer, Manipal College of Nursing, Manglore, India.

Introduction:

Normal sexuality is difficult to define. But it is easier to define abnormal sexuality. Sexual behavior is diverse and determined by a complex interaction of factors. It is affected by relationships with others, by life circumstances, and by the culture in which a person lives. Humans, like other animals, have always been interested in sexuality and have depicted almost every form of sexual behavior.

Meaning:

Sexual dysfunctions are cognitive, affective, and / or behavioral problems that prevent an individual or couple from engaging in and / or enjoying satisfactory intercourse and orgasm. Sexual dysfunctions are also seen as disturbances in one more of the sexual response cycle's phases, or pain associated with arousal or intercourse.

Sexual dysfunction refers to a person's inability to participate in a sexual relationship as he or she would wish.

Classification: (DSM IV TR)

1) sexual desire disorder

• hypoactive sexual desire disorder
• sexual aversion disorder

2) sexual arousal disorder

• female sexual arousal disorder
• male erectile disorder

3) Orgasmic disorder

• Female orgasmic disorder
• Male orgasmic disorder
• Premature ejaculation

4) Sexual pain disorder

• Dyspareunia
• Vaginisumns

5) sexual dysfunction due to a general medical condition

ICD 10 Classification:

1.      Lack or loss of sexual desire

2.      Sexual aversion and lack of sexual enjoyment

3.      Failure of genital response

4.      Orgasmic dysfunction

5.      Premature ejaculation

6.      Non orgaanic vaginismus

7.      Non organic dyspareunia

8.      Excessive sexual drive

9.      Other sexual dysfunction

10.  Unspecified sexual dysfunction

TYPES:

I. sexual desire disorders :

a) Hypoactive sexual desire disorder  :

It is characterized by a persistent or recurrent deficiency or absence of sexual fantasies and desire for sexual activity. The complaint is more common in women than in men.

b) Sexual aversion disorder :

This disorder is characterized by a persistent or recurrent extreme aversion to, and avoidance of, all genital sexual contact with a sexual partner.

Individuals displaying hypoactive desire are often neutral or indifferent toward sexual interaction, but sexual aversion implies anxiety, fear or disgust in sexual situations.

II. Sexual arousal disorder:

a) Female sexual arousal disorder:

It is characterized by the persistent or recurrent partial or complete failure to attain or maintain the lubrication swelling response of sexual excitement until the completion of the sexual act.

b) Male erectile disorder :

• It is characterized by the recurrent and persistent, partial or complete failure to attain or maintain an erection to perform the sex act.
• Primary erectile dysfunction refers to cases in which the man has never been able to have intercourse.
• Secondary erectile dysfunction refers to cases in which the man has difficulty getting or maintaining an erection but has been able to have vaginal or anal intercourse at least once.

III. Orgasmic disorders:

a) Female orgasmic disorder:

• It is characterized by persistent or recurrent delay in, or absence of, orgasm following a normal sexual excitement phase
• In short, a women's inability to achieve organism by masturbation or coitus

Primary orgasmic dysfunction: Never experienced orgasm  by any kind of stimulation.

Secondary orgasmic dysfunction: Experienced at least one orgasm, regardless of the means of stimulation, but no longer does so.

• Sometimes referred to as an anorgasmia.

b) Male orgasmic disorder :

It is characterized by persistent or recurrent delay in, or absence of orgasm following a normal sexual excitement phase.

• Sometimes called retarded ejaculation
• A man with lifelong orgasmic disorder was never been able to ejaculate during coitus.

Primary disorder: History of never having experienced an orgasm.

Secondary disorder: Occasional problems in ejaculation.

c) Premature ejaculation :

It is described as persistent or recurrent ejaculation with minimal sexual stimulation before, on, or shortly after penetration and before the person wishes it.

• 35-40% of men treated for sexual disorders have premature ejaculation as the chief complaints.

IV. Sexual pain disorders:

a) Dyspareunia: It is recurrent or persistent genital pain occurring in either men or women before, during, or after intercourse.

• More common in women
• It is related to, and often coincides with, vaginismus.
• In women, the pain may be felt in the vagina, around the vaginal entrance and clitoris, or deep in the pelvis.
• In men, the pain is felt in the penis

b) vaginismus: it is an involuntary constriction of the outer one third of the vagina that prevents penile insertion and intercourse.

V. Sexual dysfunction due to a general medical condition and substance induced sexual dysfunction:

Types of medical conditions that are associated with sexual dysfunction include;

• Neurological (multiple sclerosis, neuropathy)
• Endocrine (diabetes mellitus, thyroid dysfunctions)
• Vascular (atherosclerosis)
• Genitourinary (testicular disease, urethral or vaginal infections).
• Substances (alcohol, amphetamines, cocaine, opioids, sedatives, hypnotics, anxiolytics, antidepressants, antipsychotics and antihypertensive).

ETIOLOGY: (Hgam, 1978).

1) Psychological causes:

• Stress or anxiety from work or family responsibilities
• Concern about sexual performance
• Conflicts in the relationship with partner.
• Depression / anxiety
• Unresolved sexual orientation issues.
• Previous traumatic sexual or physical experience
• Body image and self esteem problems.

2) Physical causes :

• Diabetes, hearts disease, liver disease, kidney disease, pelvic surgery, pelvic injury or trauma, neurological disorders, medication side effects, hormonal changes, alcohol or drug abuse, fatigue.

3) Interpersonal relationship :

• Partner performance and technique
• Lack of partner
• Relationship quality and conflict.
• Lack of privacy

4) Socio cultural :

• • Inadequate education
  • Conflict with religious, personal or family values.
  • Societal taboos.

TREATMENT:

Basic principles of direct treatment of sexual dysfunction (Lopiccolo, 1978)

1. mutual responsibility
2. information and education
3. attitude change
4. eliminating performance anxiety
5. increasing communication and effectiveness of sexual technique
6. changing destructive life styles and sex roles
7. prescribing changes in behavior

1) Biological treatment :

a) Pharmacotherapy :

• Sildenafil, oral phentolamine, alprostadil transurethral alprostadil (erectile disorder)
• Intravenous methohexital sodium has been used in desensitization therapy.
• Antianxiety agents.
• Bromocriptive, a dopamine agonist, may improve sexual function impaired by hyperprolocatinemia.
• Dopaminergic agents have been reported to increase libido and improve sex function.

b) Hormone therapy :

• androgens increase the sex drive.
• Antiandrogens have been used to treat compulsive sexual behavior in men.
• Antiestrogens increases libido

c) Mechanical treatment approaches :

Vacuum pump: These are mechanical devices that patients without vascular diseases can use to obtain erections. The blood drawn in to the penis following the creation of the vacuum is kept there by a ring placed around the base of the penis.

EROS: A device developed to create clitoral erections in women. It is a small suction cup that fits over the clitoral region and drawn blood in to the clitoris.

d) Surgical treatment:

• Male prostheses
• Vascular surgery
• Hymenectomy for dyspareunia
• Vaginoplasty and release of vaginal adhesions

2) Dual sex therapy:

(William masters & Virginia Johnson)

• Treatment is based on a concept that the couple must be treated when a dysfunctional person is in a relationship
• Both are involved in a sexually distressing situation, both must participate in the therapy program.
• The keystone of the program is the round table session in which a male and female therapy team clarifies, discusses, and works through problems with the couple.
• Treatment is short term and behaviorally oriented
• Therapist suggests specific sexual activities.
• Initially, intercourse is inter directed and the couple learn to give and receive bodily pleasure without the pressure of performance or penetration.
• The aim of the therapy is to establish an effective communication within the marital unit.
• Psychotherapy sessions follow each new exercise period, and problems and satisfactions are discussed.

Specific techniques of exercises:

• Vaginismus: Woman is advised to dilate her vaginal opening with her fingers or with dilators
• Premature ejaculation :

a)      sequeeze technique is used to raise the threshold of penile excitability. In this exercise the man or the woman stimulates the erect penis until the earliest sensations of impending ejaculation are felt. At this point, the woman forcefully sequeezes the coronal ridge of the gland, the erection is diminished, and ejaculation is inhibited.

b)      stop start technique in which the woman stops all stimulation of the penis when the man first senses an impending ejaculation

• Erectile disorder: sometimes told to masturbate to prove that full erection and ejaculation are possible.
• Lifelong female orgasmic disorder: women is directed to masturbate, sometimes using a vibrator.

3) Hypnotherapy :

Focus specifically on the anxiety producing situation - that is, the sexual interaction that results in dysfunction.

4) Behavior therapy :

Behavior therapists assume that sexual dysfunction is learned maladaptive behavior, which causes patients to be fearful of sexual interaction.

• Hierarchy of anxiety provoking situations
• Ranging from least threatening to most threatening
• Systematic desensitization
• Assertiveness training

5) Group therapy :

Used to examine both intra psychic and interpersonal problems in patients with sexual disorders.

• Groups can be organized in several ways.

6) Analytically oriented sex therapy :

The sex therapy is conducted over a longer period than usual, which allows learning or relearning of sexual satisfaction under the realities of patient's day-to-day lives.

Nursing management :

1) Sexual dysfunction

• Assess client's sexual history and previous level of satisfaction in sexual relationship.
• Assess client's perception of the problem
• Assess client's level of energy
• Review medication regimen, observe for side effects
• Provide information regarding sexuality and sexual functioning
• Refer for additional counseling or sex therapy if required.

2) Ineffective sexuality patterns.

Take sexual history, noting client's expression of areas of dissatisfaction with sexual pattern.

Assess areas of stress in client's life and examine relationship with sexual partner.

Note cultural, social, ethnic, racial, and religious factors that may contribute to conflict regarding variant sexual practices.

Be accepting and non judgmental

Assist therapist in plan of behaviour modification to help client decrease variant behaviours.

Teach client that sexuality is a normal human response and is not synonymous with any sexual act. Client must understand that sexual feelings are human feelings.

Conclusion:

Nurse may become involved in the primary prevention process. The focus of primary prevention is to intervene in home life or other facets of childhood in an effort to prevent problems from developing. An additional concern of primary prevention is to assist in the development of adaptive coping strategies to deal with stressful life situation.

REFERENCES:

1. Benjamin J S, Sadock VA. Synopsis of psychiatry. Lippincott Williams &wilkins ; Philadelphia : 2007.
2. Benjamin JS, Sadock UA. Comprehensive text book of psychiatry. Lippincott Williams & wilkins; Philadelphia: 2005.
3. Niraj Ahuja. A short text book of Psychiatry Jaypee brothers medical publishers; New Delhi: 2006.
4. Katherine MF, Worret  PAH. Psychiatric mental health nursing. Mosby, St. louis : 2008.
5. Louise Rebance shives. Psychiatric mental health nursing. Lippincott Williams & wilkins; Philadelphia : 2008.
6. 1.      Leonardo F F et al. Sexual dysfunction in patients with OCD and Social anxiety disorder. The J of Nervous and Mental Disease. 195(3): 2007.
7. Anita HC et al. Symptoms of sexual dysfunction in patients treated for major depressive disorder. J Clin Psychiatry, 2007: 68: 1860-1866.
8. Rakesh G et al . A variant o Dhat syndrome. Indian journal of psychiatry, 49: 2007.
9. Arackal BS et al. prevalence of sexual dysfunction in male subjects with alcohol dependence. Indian journal of Psychiatry. 49(2):2007