MADE BY: ENRIQUEZ, REANNE S.
ATENEO DE ZAMBOANGA UNIVERSITY
NCM 117 PSYCHOLOGY WEEK 2: PHOBIAS, PTSD, OCD
Phobias
• It is an illogical, intense, and persistent fear of a
specific object or a social situation that causes
extreme distress and interferes with normal
functioning
• Phobias usually do not result from past negative
experiences.
• People with phobias have a reaction that is out of
proportion to the situation or circumstances
• Person with phobia develop anticipatory anxiety
even when thinking about possibly encountering
the dreaded phobic object or situation.
• They engage in avoidance behavior that often
severely limits their lives—avoidance behavior
usually does not relieve the anticipatory anxiety for
long.
• There are three categories of phobias:
o Agoraphobia
o Specific phobia—irritational fear of a
particular object or a situation
o Social anxiety or phobia—anxiety provoked
by certain social or performance situations
• The diagnosis of a phobic disorder is made only
when the phobic behavior significantly interferes
with the person’s life by creating marked distress or
difficulty in interpersonal or occupational
functioning.
• Specific phobias are subdivided into the following
categories:
o Blood-injection phobias: fear of seeing
one’s own or others’ blood, traumatic injury,
or an invasive medical procedure
o Situational phobias: fear of being in a
specific situation such as on a bridge or in
a tunnel, small room, and elevator
o Animal phobia: fear of animals and can
continue through adulthood in both men
and women: common are dogs and cats
o Other types of specific phobias: fear of
getting lost while driving
• In social phobia or Social anxiety disorder—the
person becomes severely anxious to the point of
panic or incapacitation when confronting situations
involving people
• The fear is rooted in low self-esteem and concern
about other’s judgements
• A person may have one or several social phobias;
the latter is known as generalized social phobia
Onset and Clinical course
• Specific phobias usually occur in childhood or
adolescence
• The peak of onset for social phobia is middle
adolescence; it sometimes emerges in a person
who was shy as a child
• The course of social phobia is often continuous,
though the disorder may become less severe
during adulthood
• Severity of impairment fluctuates with life stress
and demands
Treatment
BSN3-L
ILAH REANNE S, ENRIQUEZ
• Behavioral therapy works well—initially focus on
teaching what anxiety is:
o helping the client identify anxiety
responses
o teaching relaxation techniques
o setting goals, discussing methods to
achieve those goals
o helping the client visualize phobic
situations
o Therapies that help the client develop
self-esteem and self-control
o positive reframing and assertiveness
training
• behavioral therapy is systemic (serial)
desensitization—therapist progressively
exposes the client to the threatening object in a
safe until the client’s anxiety decreases.
o During each exposure, the complexity
and intensity of exposure gradually
increase, but the client’s anxiety
decreases
o The reduced anxiety serves as positive
reinforcement until the anxiety is
ultimately eliminated.
o Ex. Client who fears flying, the therapist
would encourage the client to hold a
small model plan while talking about his
or her experiences
o Each session’s challenge is based on
the success achieved in previous
sessions
• Flooding is a form of rapid desensitization in
which a behavioral therapist confronts the client
with phobic object until it no longer produces
anxiety by showing a picture or the actual object
o Because the client’s worst fear has been
realized and the client did not die, there
is a little reason to fear the situation
anymore
• The goal is to rid the client of the phobia in one
or two sessions
• This method is highly anxiety producing and
should be conducted only by a trained
psychotherapist
General Anxiety Disorder
• A person with GAD worries excessively and
feels highly anxious at least 50% of the time for
6 months or more
• The person has three or more of the following
symptoms:
o Uneasiness, irritability muscle tension,
fatigue, difficulty thinking, and sleep
alterations
• Treatments: Buspirone (BuSpar) and SSRI or
serotonin-norepinephrine reuptake inhibitor
antidepressants
• Disorders that include Excessive Anxiety:
o Obsessive-Compulsive disorder
o Posttraumatic stress disorder (PTSD)
Posttraumatic Stress Disorder (PTSD)
NCM 117 PSYCHOLOGY WEEK 2: PHOBIAS, PTSD, OCD
• May occur in people who have experienced or
witness a traumatic event, series or events or
set of circumstances
• Emotionally or physically harmful or life-
threatening and may effect mental, physical,
social, and spiritual well-being
• Natural disasters, serious incidents, terrorist
acts, war/combat, rape/sexual assault, historical
trauma, intimate partner violence and bullying
• Many names:
o World war I: Shell shock
o World war II: Combat fatigue
Symptoms and Diagnosis of PTSD
• Categories of symptoms (vary in severity)
1. Intrusion: intrusive thoughts such as repeated
involuntary memories; distressing dreams; or
flashbacks of the traumatic event
2. Avoidance: avoiding remainders of traumatic event
may include avoiding people, places, activities, and
situations that may trigger distressing memories
• May resist talking about what happened or how
they feel about it
3. Alterations in cognition and mood: inability to
remember important aspect of the traumatic event,
negative thoughts and feelings leading to on going
and distorted beliefs about oneself or others (e.g.,
“No one can be trusted”);
• distorted thoughts about the causes or
consequence of the event leading to wrongly
blaming self or others
• ongoing fear, horror, anger, guilt, or shame;
much less interest on the activities previously
enjoyed; feeling detached or estranged from
others; or a being unable to experience positive
emotions (a void of happiness or satisfaction)
4. Alteration in arousal in and reactivities: arousal
and reactive symptoms may include being irritable
and having any outburst; behaving recklessly or in
a self-destructive way; being overly watchful one’s
surroundings in a suspected way; being easily
startle or having problems in concentrating
Cognitive Behavioral Therapy
• One category of psychotherapy, cognitive
behavior therapies (CBT) is very effective.
• Cognitive processing therapy—prolonged
exposure therapy and stress inoculation therapy
are among the types of CBT used to treat PTSD
• Cognitive processing therapy: evidenced-
based, cognitive behavioral therapy designed
specifically to treat PTSD and comorbid
symptom. It focuses in changing painful negative
emotions and beliefs due to the trauma
o Therapist help the person confront such
distressing memories and emotions
• Prolonged exposure therapy: uses repeated,
detailed imagining of the trauma in progressive
exposures to symptom “triggers” in a safe,
ILAH REANNE S, ENRIQUEZ
controlled way to help a person face and gain
control of fear and distress and learn to cope
o For example, virtual reality programs
have been used to help war veterans
with PTSD re-experience the battlefield
in a controlled and therapeutic way
• Trauma Focused Cognitive Behavioral
Therapy: evidenced based treatment model for
children and adolescents that incorporates
trauma-sensitive interventions with cognitive
behavioral, family, an/humanistic principles, and
techniques
• Group therapy: encourages survivors of similar
traumatic events to share these experiences and
reactions in a comfortable and non-judgmental
setting. Group members help one another real
that many people would have responded the
same way and felt the same emotions
o Family therapy may also help because
the behavior and distress of the person
with PTSD can affect the entire family
Clinical Course
• Symptoms occur 3 months or more after the
trauma, which distinguishes PTSD from acute
stress disorder, which may have similar types of
symptoms buts lasts 3 days up to 1 month
• The onset can be delayed for months or even
years.
• Typically, PTSD is chronic in nature, through
symptoms can fluctuate in intensity and severity,
becoming worse during stressful periods
Etiology
• There has to be causative trauma or event that
occurs prior to the development of PTSD, which
is not the case with anxiety disorders
• PTSD is a disorder associated with event
exposure-single-event trauma
Treatment
• Medications: for insomnia, anxiety, or
hyperarousal
• Studies show that selective serotonin reuptake
inhibitor and antidepressants are most effective,
followed by second generation antipsychotic
such as Risperidone
• Evidence is lacking for the efficacy of
Benzodiazepines those are widely used in
clinical practice. A combination of medications
and CBT is considered to be more effective than
either one alone
Nursing Care Plan: Client with PTSD
Nursing Diagnosis
Post trauma Syndrome: An ongoing, maladaptive pattern
of behavior in response to a traumatic event that posed
a threat to the well-being of the individual
ASSESSMENT DATA
• Flashbacks or reexperiencing the traumatic event(s)
NCM 117 PSYCHOLOGY WEEK 2: PHOBIAS, PTSD, OCD
• Nightmares or recurrent dreams of the event or other
trauma
• Sleep disturbances
• Depression
• Denial of feelings or emotional numbness
• Projection of feelings
• Difficulty in expressing feelings
• Anger
• Guilt or remorse
• Low self-esteem
• Frustration and irritability
• Anxiety, panic, or separation anxiety
• Fears (displaced or generalized)
• Decreased concentration
• Difficulty expressing love or empathy
• Difficulty expressing pleasure
• Difficulty with interpersonal relationships, marital and
divorce
• Abuse in relationships, sexual problems, substance
use
• Employment problems and physical symptom
Expected Outcomes
Immediate: The client will
• Identify the traumatic event within 24 to 48 hours.
• Demonstrate decreased physical symptoms within 2
to 3 days.
• Verbalize the need to grieve loss(es) within 3 to 4
days.
• Establish an adequate balance of rest, sleep, and
activity; for example, sleep at least 4 hours per night
within 3 to 4 days.
• Demonstrate decreased anxiety, fear, guilt, and so
forth within 4 to 5 days.
• Participate in a treatment program; for example, join
in a group activity or talk with staff for at least 30
minutes twice a day within 4 to 5 days.
Stabilization: The client will
• Begin the grieving process; for example, talk with staff
about griefrelated feelings and acknowledge the loss
or event.
• Express feelings directly and openly in nondestructive
ways.
• Identify strengths and weaknesses realistically; for
example, make a list of abilities and review with staff.
• Demonstrate an increased ability to cope with stress.
• Eliminate substance use.
• Verbalize knowledge of illness, treatment plan, or safe
use of medications, if any.
Community: The client will
• Demonstrate initial integration of the traumatic
experience into his or her life outside the hospital.
• Identify a support system outside the treatment
setting; for example, identify specific support groups,
friends, or family, and establish contact.
• Implement plans for follow-up or ongoing therapy, if
indicated;
o for example, identify a therapist and
schedule an appointment before discharge.
Implementation
1. When you approach the client, be nonthreatening and
professional.
2. Initially, assign the same staff members to the client if
possible; try to respect the client’s fears and feelings.
ILAH REANNE S, ENRIQUEZ
Gradually increase the number and variety of staff
members interacting with the client.
3. Educate yourself and other staff members about the
client’s experience and about posttraumatic behavior.
4. Examine and remain aware of your own feelings
regarding both the client’s traumatic experience and
his or her feelings and behavior. Talk with other staff
members to work through your feelings.
5. Remain nonjudgmental in your interactions with the
client.
6. Be consistent with the client; convey acceptance of
him or her as a person while setting and maintaining
limits regarding behaviors.
7. Assess the client’s history of substance use
(information from significant others might be helpful).
8. Be aware of the client’s use or abuse of substances.
Set limits and consequences for this behavior; it may
be helpful to allow the client or group to have input
into these decisions.
9. If substance use is a major problem, refer the client to
a substance-dependent treatment program.
10. Encourage the client to talk about his or her
experience(s); be accepting and nonjudgmental of the
client’s accounts and perceptions.
11. Encourage the client to express his or her feelings
through talking, writing, crying, or other ways in which
the client is comfortable.
12. Especially encourage the expression of anger, guilt,
and rage.
13. Give the client positive feedback for expressing
feelings and sharing experiences; remain
nonjudgmental toward the client.
14. Teach the client and the family or significant others
about posttraumatic behavior and treatment.
15. Help the client learn and practice stress management
and relaxation techniques, assertiveness, self-
defense training, or other skills as appropriate.
16. As tolerated, encourage the client to share his or her
feelings and experiences in group therapy, in a
support group related to post trauma, or with other
clients informally
17. If the client has a religious or spiritual orientation,
referral to a member of the clergy or a chaplain may
be appropriate
18. Encourage the client to make realistic plans for the
future, integrating his or her traumatic experience.
19. Talk with the client about employment, job-related
stress, and so forth. Refer the client to vocational
services as needed.
20. Help the client arrange for follow-up therapy as
needed.
21. Encourage the client to identify relationships, or social
or recreational situations that have been positive in
the past.
22. Encourage the client to pursue past relationships,
personal interests, hobbies, or recreational activities
that were positive in the past or that may appeal to
the client.
23. Encourage the client to identify and contact
supportive resources in the community or on the
internet.
Interventions for PTSD
• Priority: promoting the client’s safety
• Help client cope with stress and emotions
• Help promote client’s self-esteem (survivor not
victim)
• Establishing social support
Obsessive-Compulsive Disorder (OCD)
NCM 117 PSYCHOLOGY WEEK 2: PHOBIAS, PTSD, OCD
• Common, chronic, and long-lasting disorder in
which person has uncontrollable, reoccurring
thoughts (“Obsessions”) and/or behaviors
(“compulsions”) that he or she feels the urge to
repeat over and over
Etiology
• Cognitive models describe the person’s thinking
as
o Believing one’s thoughts are overly
important that is “if I think it, it will
happen” and therefore having a need to
control those thoughts
o Perfectionism and the intolerance of
uncertainty
o Inflated personal responsibility (from a
strict moral and religious upbringing)
and overstimulation of the threat wed by
one’s thoughts
• Population-based studies have confirmed
substantial heritability in OCD
Signs and symptoms
• May have symptoms of obsessions, and
compulsions or both. And can interfere with all
aspects of life
• Obsessions are repeated thoughts, urges or
mental images that cause anxiety. Common
symptoms include:
o Fear of germs or contamination
o Unwanted forbidden or taboo thoughts
involving sex, religion, or harm
o Aggressive thoughts towards self or
other
o Having things symmetrical or in a
perfect order
• Compulsions are repetitive behaviors that a
person with OCD feels the urge to do in
response to an obsessive thought. Common
compulsions include
o Excessive cleaning and/or handwashing
o Ordering and arranging things in a
particular, precise way
o Repeatedly checking on things, such as
repeatedly checking to see if the door is
locked or that the oven is off
o Compulsive counting
• Not all rituals or habits are compulsions.
Everyone doubts checks things sometimes. But
a person with OCD generally:
o Cannot control his or her thoughts or
behaviors, even when those thoughts or
behaviors are recognized as excessive
o Spends at least 1 hour a day on these
thoughts or behavior
o Does not get pleasure when performing
the behaviors or rituals, but may feel
brief relief from the anxiety the thoughts
cause.
o Experiences significant problems in their
daily life due to these thoughts or
behavior
ILAH REANNE S, ENRIQUEZ
Onset and Clinical course
• OCD can start in childhood, especially in males
• In females, more commonly begins in the 20s,
overall, distribution between the sexes is equal
• Onset is typically in late adolescence
• Can have periods of relatively good functioning
and limited symptoms
o Exacerbation of symptoms related to
stress
• Complete remission of their symptoms or a
progressive, deteriorating course of the disorder
OCD Related Disorders
• Dermatillomania: excoriation disorder, skin
picking
• Trichotillomania: chronic repetitive hair pulling
• Body Dysmorphic Disorder: preoccupation
with an imagined or slight defect of physical
appearance that causes significant stress in the
person and interferes with functioning in daily life
• Holding disorder: progressive, debilitating,
compulsive disorder
Note: The following disorders are sometimes viewed as related
to OCD that is repetitive, compulsive behavior that is potentially
harmful to the individual. Others view them as behavioral
addictions, characterized by an inability to resist the urge to
engage in potentially harmful actions
• Onychophagia: chronic nail-biting is a self-
soothing behavior
• Kleptomania: compulsive stealing is a reward-
seeking behavior
• Oniomania: compulsive buying is an acquisition
typed reward-seeking behavior
• Body Integrity Disorder (BIID): term given to
people who felt “over-complete” or alienated
from a part of the body and desire amputation
Treatment
• Medication, psychotherapy, or a combination of
two and behavioral therapy
• Behavioral therapy specifically includes
exposure and response prevention.
o Exposure involves assisting the client in
deliberately confronting the situations
and stimuli that he or she usually
avoids.
o Response prevention focuses on
delaying or avoiding performance of
rituals
o The person learns to tolerate the
thoughts and the anxiety and to
recognize that it will recede without the
disastrous imagined consequences
• Although most patients with OCD respond to
treatment, some patients continue to experience
symptoms
• Sometimes, people with OCD also have other
mental disorders, such as anxiety, depression,
and body dysmorphic disorder
• Medication of choice: SSRI- Ex. Escitalopram
NCM 117 PSYCHOLOGY WEEK 2: PHOBIAS, PTSD, OCD ILAH REANNE S, ENRIQUEZ
Nursing Care Plan

Nursing Diagnosis:

Ineffective Coping: Inability to form a valid appraisal of

stressor, inadequate choices of practiced responses,
and/or inability to use available resources

1. Assessment
• Ambivalence regarding decisions or choices
• Disturbances in normal functioning due to obsessive
thoughts or compulsive behaviors (loss of job, loss
of/or alienation of family members, etc.)
• Inability to tolerate deviations from standards
• Rumination
• Low self-esteem
• Feelings of worthlessness
• Lack of insight
• Difficulty or slowness completing daily living activities
because of ritualistic behavior
2. Expected Outcomes
• Immediate: The client will
- Difficulty or slowness completing daily living
activities because of ritualistic behavior
- Verbalize realistic self-evaluation; for example,
make a list of strengths and abilities and review
list with staff within 3 to 4 days.
- Establish adequate nutrition, hydration, and
elimination within 4 to 5 days.
- Establish a balance of rest, sleep, and activity; for
example, sleep at least 4 hours per night.
• Stabilization: The client will
- Identify alternative methods of dealing with stress
and anxiety
- Complete daily routine without staff assistance or
prompting by a specified date.
- Verbalize knowledge of illness, treatment plan,
and safe use of medications, if any.
• Community: the client will
- Demonstrate a decrease in obsessive thoughts
or ritualistic behaviors to a level at which the
client can function independently.
- Demonstrate alternative ways of dealing with
stress, anxiety, and life situations.
- Maintain adequate physiological functioning,
including activity, sleep, and rest.
- Follow through with continued therapy if needed;
for example, identify a therapist and make a
follow-up appointment before discharge.