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What is anxiety?
- Universal human experience
- Feeling of apprehension, uneasiness, uncertainty, dread
- Resulting from a real or perceived threat
- Actual source is unknown or unrecognized w/ exception of specific phobias
- Can be differentiated from fear
- Normal mild anxiety is healthy and motivated people to make changes
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Anxiety vs. fear
- Anxiety:
- Reaction to an unspecified danger
- Results from real or perceived threats, source of threats is unknown or unrecognized
- Acute anxiety - results from imminent loss or change/challenge that threatens person's sense of security (ex: performance on exam)
- Chronic anxiety - trait anxiety; person has lived with for a long time; personality trait; permanent
- SNS activates body's response during anxiety
- PNS conserves responses
- Fear:
- Reaction to a specific danger or known danger
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Mild anxiety
- Can enhance learning
- Perceptual field heightened
- Grasps what is happening
- Identifies disturbed things
- Can work toward a goal and examine alternatives
- Slight discomfort, restlessness, irritability
- Mild tension relieving behaviors
- Some form of mild anxiety before an exam is good; motivates you to study
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Moderate anxiety
- Perceptual field narrows
- Selective attention to details and info
- Needs to have things pointed out
- Problem solving ability moderately impaired
- Benefits from guidance
- Shaky voice, concentration difficult
- SNS symptoms: incr pulse, incr BP, feeling flushed
- Somatic symptoms: headache, incr fatigue
- Important to give discharge instructions verbally and in writing because pt only will hear part of what you are saying
- Not healthy level for students taking exams
- Task is to lower level to mild level
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Interventions for mild to moderate anxiety
- Help identify anxiety and antecedents to anxiety
- Anticipate anxiety-provoking situations
- Demonstrate interest
- Encourage talk about feelings and concerns
- Keep communication open
- Use clarification to understand
- Encourage problem solving
- Use role playing, modeling
- Explore behaviors used in past
- Provide outlets for excess energy
- Build on their strengths
- Work on one goal at a time; don't overwhelm pt
- Keep milieu safe and calm
- Decr stimuli; be aware pt's are watching and modeling their behavior on what they see
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Severe anxiety
- Perceptual field greatly reduced; perceptions are distorted
- Attention scattered; learning is impossible
- Self-absorbed
- Can't attend to events or see connections
- Can only focus on 1 object
- Feelings of dread/doom
- SNS symptoms (headache, nausea, dizziness, pounding heart)
- Confusion, purposeless activity but still basically functional
- Can be redirected with firmness
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Panic level anxiety
- Unable to focus on environment
- Terror, emotional paralysis
- Hallucinations/delusions
- Muteness, severe withdrawal
- Immobility or extreme agitation, severe shakiness
- Disorganized, irrational thinking
- Unintelligible speech
- Sleepiness
- Panic attack: severe form of anxiety; usually short lived; stay w/ pt make sure they are safe; give meds (benzos); speak calmly; help them gain a sense of control
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Interventions to severe to panic anxiety
- Maintain calm manner
- Remain with client
- Minimize environmental stimuli
- Use clear, simple statements and repetition
- Low pitched voice, speak slowly
- Reinforce reality if distortions occur
- Listen for themes
- Meet physical and safety needs
- Set verbal limits and physical limits
- Assess need for medication or seclusion
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Defenses against anxiety
- Manage conflict and affect
- Are relatively unconscious
- Are discrete from one another
- Are often hallmarks of psychiatric syndromes
- Are reversible
- Are adaptive as well as pathological, maladaptive
- Done to block unconscious thoughts
- Can be unlearned
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Mature defenses
- Altruism
- Sublimation
- Humor
- Suppression
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Altruism
- Emotional conflicts and stressors are dealt with by meeting the needs of others
- Decr anxiety by doing good deeds or reaching out toward others (ex: 12th step of AA program)
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Sublimation
- Unconscious process
- Substituting constructive and socially acceptable activity for strong impulses that are not acceptable
- Consciously unacceptable instinctual drives are diverted into personally and socially acceptable channels
- Transfer of anxiety related to unacceptable inner feelings of sexual or aggressive urges into a constructive or socially acceptable activity
- Ex: someone with unacceptable sexual urges may go into art or music which is socially acceptable method of expressing these urges
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Humor
- The individual deals with emotional conflicts or stressors by emphasizing the amusing or ironic aspects of the conflict through humor
- Can be unhealthy if used too frequently
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Suppression
- Conscious denial of a disturbing situation or feeling until you have to deal with the situation or feeling
- Compartmentalize worry
- Ex: I won't worry about paying my rent until after my exam tomorrow
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Neurotic (Intermediate) Defenses
- Repression
- Displacement
- Intellectualization
- Reaction formation
- Somatization
- Undoing
- Rationalization
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Repression
- Unconscious
- Exclusion of unwanted experiences, emotions or ideas from conscious awareness
- Keeps out of conscious what has never been conscious (sexual assault, war trauma; may experience weeping for no reason or feelings they don't understand)
- Allows person to get through the anxiety-ridden event
- Can become unhealthy when memories become deeply unconscious
- Ex: nurse working in ER where pt is coding, nurse represses any anxiety may be feeling
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Displacement
- Unconscious transfer of emotions associated with a particular person, object or situation to another person that is nonthreatening
- Ex: a patient criticizes a nurse after his family fails to visit
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Intellectualization
- Thinking about instinctual wishes in formal, affectively bland terms
- Includes mechanisms of isolation, rationalization, undoing, magical thinking
- Anxiety in conscious but feeling behind in conscious mind
- Events are analyzed based on remote, cold facts and without passion, rather than incorporating feeling and emotion into the processing
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Reaction formation
- Unacceptable feelings or behaviors are kept out of awareness by developing the opposite behavior or emotion
- Overcompensation
- Ex: ex-smoker who is still having anxiety about cravings begins speaking outwardly and poorly about smokers and not being around smokers
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Somatization
- Transferring anxiety on a conscious level to a physical symptom that has no organic cause
- Ex: feel nervous about giving a presentation, develop a sore throat or laryngitis so can't give lecture
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Introjection
- Unconscious lowering of anxiety by incorporation of values or qualities of an admired person or group onto one's own ego structure
- Found most commonly in adolescents
- Ex: pick someone in peer group and unconsciously start dressing like that person or listening to same music, stc.
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Undoing
- Unconscious undoing that makes up for an act or communication
- Ex: get anxious and eat a pan of brownies and then go out and run for an hour and a half
- Ex: domestic violence; try to undo negative behavior by giving victim flowers or gifts
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Rationalization
- Justifying illogical or unreasonable ideas, actions or feelings by developing acceptable explanations that satisfy the teller as well as the listener
- ex: A man who thinks his son was fathered by another man excuses his malicious treatment of the boy by saying, "he is lazy and disobedient", when that is not the case.
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Immature defenses (personality disorders)
- Passive aggressive
- Acting out behaviors
- Dissociation
- Devaluation
- Idealization
- Splittiing
- Projection
- Almost always maladaptive and negative
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Passive aggressive
- Dealing with emotional conflicts/anxiety indirectly or unassertively
- On the surface, appearance of acceptance that hides resistance, resentment, hostility
- Ex: procrastination, inefficiency, failure, passivity, and illnesses that affect others more than oneself
- Ex: smiling at someone and agreeing and then talking about the person behind their back and not following through
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Acting out behaviors
- Dealing with emotional conflict/anxiety with physical behaviors
- Primary gain: by lashing out, transfers the focus from the personal doubts/pain to some other person or object
- Secondary gain: incr attention, comfort they get from acting out these behaviors
- Children and adolescents
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Dissociation
- Unconscious defense mechanism
- Allows blocking of overwhelming anxiety
- A disintegration of functions of consciousness, memory, identity or perceptions of environment
- Derealization - feeling of unreality relative to environment
- Depersonalization - feeling of being detached from oneself or out of body experience
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Devaluation
- Unconscious
- Attribute negative qualities to self or others in an attempt to decr anxiety regarding emotional conflicts/stressors
- Ex: win student of the month but are very anxious that you can't maintain the standards; when someone congratulates student they devalue the achievement by saying that it doesn't mean anything
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Idealization
- Overvaluing of a person in an attempt to decr anxiety
- Ex: woman had multiple bad relationships, is in a new relationship and has anxiety that new relationship will also be a bad relationship
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Splitting
- Inability to integrate the positive and negative qualities of oneself or others into a cohesive image
- See all good or all bad
- Common in borderline personality disorder
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Projection
- Unconscious
- Rejection of emotionally unacceptable personal features and attributes them to other people, objects or situations
- Freq in people with paranoia
- "What you say is what you are"
- Person does a lot of blaming or scape-goating
- Ex: Person that thinks low of self, thinks other people hate them too
- Ex: New nurse that feels very inadequate at their job, projects blame onto another nurse when they make a mistake
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Denial
- Unconscious
- Escaping unpleasant realities by ignoring their existence
- People who abuse substances
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Regression
- Retreat to an earlier level of development and the comfort measures associated with that level of functioning
- Ex: 3 and 4 year olds regress at birth of new sibling (i.e. start soiling their pants again)
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