焦虑患者的管理

,李应群,焦虑症的评估和管理,焦虑 焦虑的防御机制焦虑症焦虑症的护理,“全民焦虑时代”来了？,What is anxiety ？,焦虑是人们遇到某些事情、挑战、困难或危险时出现的一种指向未来的情绪反应。正常焦虑：一般情况有明确诱因，适度的焦虑，属于正常焦虑。病态焦虑：指不适当的焦虑表现，多没有明确的致焦虑因素，或有明确致焦虑因素，但反应程度、持续时间与致焦虑因素不相称，是“非同寻常”的一类焦虑反应。,两者之间可以是一个连续过程，没有绝对的界限,焦虑与恐惧的区别,焦虑指向未来，恐惧指向现在。大多数情况下，这种说法是对的。但这是一个充分不必要条件焦虑和恐惧的区别在于强度，焦虑比较轻，恐惧比较强烈.焦虑是个人内在意思的感觉，是一种不愉快的情绪体检，所担心的事情可能不确定；恐惧是一种认知过程，有具体的外在刺激，所表现的是对现实的客观威胁的一种情绪反应，且这种情绪情绪反应与现实威胁适应，理智的估计，并随着威胁的消失而消失。焦虑和恐惧的区别不在于对象、时态和强度，而在方向。焦虑是“趋”，恐惧是“避”。,焦虑的原因,应激因素-压力是导致焦虑最主要的原因失业的压力失恋的压力 失学的压力晋升的压力人际关系的压力发财的压力健康的压力环境的压力,焦虑的原因,焦虑的素质因素童年经历态度 悲观归因 乐观归因人格 坚韧 幽默,焦虑分类,Three categoriesnormal acute chronic Four levels mild moderate severe panic,Defenses Against Anxiety,Most healthy defensesIntermediate defensesImmature defenses,Altruism 利他主义Sublimation 升华作用 Humor Suppression 压制,Repression 压抑cornerstone defense mechanismDisplacement Reaction formation反作用形成 Somatization 躯体化Undoing 抵消Rationalization,Passive aggressionActing-out behavior 潜意显现行为Dissociation 分裂Devaluation 贬低 Idealization Splitting 隔离Projection Denial,轻度的焦虑有益于人的思维发散对人是一种激励过度的焦虑便会演化为焦虑症，从而给人带来影响和伤害焦虑症是以广泛性焦虑症和发作性惊恐状态为主要临床表现，常伴有头晕、胸闷、心悸、呼吸困难、口干、尿急、尿频，震颤和运动性不安等症，其焦虑并非由实际威胁所引起，或其紧张惊恐度与现实情况很不相称,病因,遗传因素 大量研究表明焦虑障碍倾向家庭聚集神经化学因素 去甲肾上腺素理论，GABA理论,乳酸心理学理论 行为理论认为焦虑是学习而得的反应；认知行为理论认为惊恐发作是不正常的一种害怕Freud 心理分析理论认为焦虑与早期发展有关，惊恐障碍是由于对潜意识冲突不成功防御的结果Sullivan 焦虑的传递学说 文化因素 躯体症状 vs 认知症状,Anxiety prevalence,In United States, 13.3% adult population ，major in women$22 billion per year90% people with anxiety develop another psychiatric disorderDepression and substance abuse have negative impact on treatment,Anxiety Disorders,Panic disorder 惊恐性障碍Phobias 恐怖症 Generalized anxiety disorder (GAD)Obsessive-compulsive disorder (OCD) Posttraumatic stress disorder (PTSD)Acute stress disorderAnxiety due to substance Anxiety due to medical conditionsAnxiety not otherwise specified,Panic disorder without agoraphobiaSimple agoraphobia Panic disorder with agoraphobia,Jim is a 28-year-old man who suffers from panic attacks with agoraphobia. He once lived a very active life, often participating in thrill-seeking activities like bungee jumping and skydiving. Jims father, who had severe cardiovascular disease, died 2 years previously on his way to work. Since that time , Jim has become increasingly fearful of the outdoors. He has gradually stopped leaving the family home because he experiences panic attacks; he fears that he will die if he leaves home.,Specific phobias Alcohol or drugsSocial phobiasTim ,a 22-year-old music theater major, develop a fear of performing on stage. He suffers severe anxiety attacks whenever he is scheduled to appear in a student production. Recently, he has become severely anxious when he is faced with giving classroom reading or singing solo in music class. He is thinking about changing his major.,Symptoms RestlessnessFatiguePoor concentrationTension Irritability 过敏，易怒Sleep disturbance,Background GAD high prevalence rate somatic complain, workplace absenteeism CBT (cognitive-behavioral therapy )in the treatment of GADSubjective studies 16 experiments ,2/3 clients were women ,mean 40 years ,mea n 7 years duration GAD, mean time of treatment 11 sessions Intervention teaches clients self-monitoring and observe their anxiety triggers ,relaxation training ,cognitive therapy , rehearsal of coping responses Control low-dose diazepam therapy ,placebo, supportive listening, and not treatment Results 6-month and 12-month follow-up CBT groups improved significantly by standardized anxiety questionnaires Implications for nursing practice teach clients with GAD , refer clients to appropriate resources in the community ,relaxation exercises,Studies,Obsessions 强迫意念 Compulsions 强迫行为 “Everything must be in its place”is the recurrent thought. Man repeatedly has the thought “ I should kill her” when he sees a blonde woman,The features of PTSDReexperiencing of the trauma through intrusive recollections of the events through dreams and through flashbacksAvoidance of stimuli with the trauma After the trauma ,experience of numbing general responsiveness ,feeling estranged from othersAfter the trauma ,experience of persistence symptoms of increased arousal .difficulty sleeping, hypervigilance,Acute stress disorder,Symptoms after 1 month after the highly traumatic eventSubjective sense of numbing, detachment ,or absence of emotional responsivenessA reduction in awareness of surroundings Derealization 现实感丧失Depersonalization 人格解体，人性丧失Dissociative amnesia 健忘症Diagnosis must have at least three dissociativesymptoms, resolves within 4 weeks,Substance-induced anxiety disorder is characterized by symptoms of anxiety, panic attacks, obsessions, and compulsions that develop with the use of a substance or within a month of stopping use of the substanceThe symptoms of Anxiety due to medical conditions are a direct physiological result of a medical condition，such as hyperthyroidism 甲亢Anxiety disorder not otherwise specified 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,AssessmentDiagnosesOutcome criteriaPlanning InterventionEvaluation,Application Of The NursingProcess,Overall symptoms of anxiety Defenses used in anxiety disordersSelf-assessment OCD clients can not accomplish tasks with a given time and communicate effective Behavioral change of phobic clients is often accomplished slowly Nurses experiences increased tension and fatigue from mental strain when working with anxiety clients Note culture,心理量表在焦虑评定中的应用,焦虑自评量表（SAS） 由Zung于1971年编制汉密顿焦虑量表（HAMA）由Hamilton于1959年编制测验焦虑量表（TAI） 由美国佛罗里达州大学的著名临床心理学家施皮尔伯格于1980年编制完成，是目前国际上最有效且应用最广泛的考试焦虑量表。显性焦虑量表（MAS）贝克焦虑量表（BAI） 由美国阿隆贝克（Aaron T.Beck）等于1985年编制综合性医院焦虑抑郁量表（HAD） 由Zigmond as与Snaith RP于1983年创制交往焦虑量表(IAS)：社交回避及苦恼量表(SAD),Anxiety (moderate, severe, panic)FearIneffective copingSocial isolation Disturbed thought processesPosttrauma syndromeDisturbed sleep patternFatigueHopelessnessChronic low self-esteem Impaired skin integrity Imbalanced nutrition :less (more) than body requirementsself-care deficitSpiritual distressIneffective role performance,Some of the NOC-recommended outcomes related to anxiety include the following:Anxiety self-control: personal actions to eliminate or reduce feelings of apprehension, tension, or uneasiness from an unidentifiable sourceCoping: personal actions to manage stressors that tax an individuals resource Self-Esteem: personal judgment of self-worthKnowledge: disease process: extent of understanding conveyed about a specific disease process,Overall guidelines for basic nursing inte