Psy Wk 4, Ex 2 Anxiety and Stress Disorders - Mental Health Nursing

Anxiety vs. Fear

Fear is response to a known threat; anxiety is response to an unknown threat.

Adaptive Anxiety

Normal, protective stress response that motivates action and improves performance.

Maladaptive Anxiety

Disproportionate, persistent anxiety that impairs daily functioning.

Physiological Basis of Anxiety

Triggers fight-or-flight, leading to increased HR, BP, and RR; pupils dilate, muscles tense, cortisol and adrenaline release

Peplau's Level 1: Mild Anxiety

Heightened alertness, sharpened senses, and optimal state for learning.

Peplau's Level 2: Moderate Anxiety

Narrowed perceptual field and selective inattention; client can still follow directions but may repeat questions. Refocus and Guide here

Peplau's Level 3: Severe Anxiety

Greatly reduced perception focusing on one detail; overwhelming dread and somatic symptoms. Stay present and reduce stimuli for client

Peplau's Level 4: Panic Anxiety

Loss of rational thought, terror, immobilization or extreme agitation; requires safety and brief commands

Repression

Involuntary, unconscious exclusion of painful thoughts or memories from awareness.

Suppression

Voluntary, conscious blocking of unpleasant feelings or thoughts.

Projection

Attributing one's own unacceptable feelings or impulses onto others.

Rationalization

Offering logical-sounding reasons to justify unacceptable behaviors or feelings.

Displacement

Redirecting emotions from the original threat to a safer substitute target.

Sublimation

Channeling unacceptable impulses into socially productive, acceptable activities.

When defense mechanisms become clinically significant

When they become the primary coping strategy

Generalized Anxiety Disorder (GAD) Diagnostic Criteria

Excessive, uncontrollable worry present more days than not for at least 6 months.

GAD Primary Physical Symptoms

Requires ≥3 of: restlessness, fatigue, poor concentration, irritability, muscle tension, sleep disturbance.

GAD Nursing Priorities

Screen for suicidality and comorbid depression

Reduce environmental stressors

Teach progressive muscle relaxation + diaphragmatic breathing

Use open-ended, reflective language

Medication education (SSRIs, SNRIs, Buspirone)

Monitor caffeine/stimulate intake, encourage journaling and structured worry time

What two disorders are highly comorbid?

GAD and MDD

Panic Attack Cycle

1. [No] Trigger

2. Acute Panic Attack

3. Anticipatory Anxiety

4. Avoidance Behavior

5. Agoraphobia

Acute Panic Attack Symptoms

Peaks within 10 minutes; Palpitations, diaphoresis, trembling, shortness of breath, chest pain, nausea, dizziness, paresthesias, chills/hot flashes, derealization, fear of dying or losing control.

Anticipatory Anxiety

Fear of anticipating another attack; Hypervigilant to bodily sensations; Constant "what if"

Avoidance Behavior

Functional limitation increases; Avoids places and situations associated w/ attack

Panic Attack Emergency Priority

Rule out cardiac causes first, as chest pain mimics myocardial infarction and pulmonary embolism.

Nursing Priorities for Phobia-Related Disorders

Used Trauma-informed approach, evidence-based therapy, and pharmacology

Blood-Injection-Injury (BII) Phobia Response

Triggers initial SNS arousal followed by a vasovagal rebound causing bradycardia and syncope.

Agoraphobia

Fear of open or public spaces where escape or getting help might be difficult; Px may become housebound

Obsessive-Compulsive Disorder (OCD)

Recurrent intrusive thoughts (obsessions) relieved temporarily by repetitive behaviors (compulsions).

Body Dysmorphic Disorder (BDD)

Preoccupation with perceived physical defects leading to repetitive mirror checking or reassurance seeking; Elevated suicide risk

Hoarding Disorder

Persistent difficulty discarding possessions resulting in unsafe living conditions

Trichotillomania

Recurrent compulsive pulling of one's own hair resulting in noticeable hair loss.

Excoriation Disorder

Recurrent compulsive skin picking resulting in skin lesions.

Acute Stress Disorder (ASD) Duration + Onset

Symptom duration of 3 days up to 1 month post-trauma.

ASD and PTSD Trauma Criterion

Exposure to actual or threatened death, serious injury, or sexual violence (could be directly, witnessed, or learned of from close relationships)

ASD Symptom Domains

Intrusion, Negative Mood, Dissociation, Avoidance, Hyperarousal

PTSD Symptom Domains

Intrusion (via flashbacks, nightmares), Avoidance, Negative Cognitions/Mood, Hyperarousal/Reactivity

PTSD Specifiers

With dissociative symptoms — Delayed expression is also possible (onset occurs 6+ months post-trauma)

Post-Traumatic Stress Disorder (PTSD) Duration

Symptom duration persisting for more than 1 month post-trauma.

PTSD Elevated Population Risk

Combat veterans, Sexual Assault Survivors, First Responders

Evidence-Based Treatments for PTSD

CPT - EMDR — Prolonged Exposure

Meds — Sertraline, Paroxetine, Prazosin

Prazosin in PTSD

Alpha-1 blocker prescribed specifically to reduce trauma-related nightmares.

For trauma

Say "Experience" not "incident"

Ask permission before touching

Offer choices to restore a sense of control

Knock before entering

Explain all procedures before initiating

SSRI/SNRI Onset of Action

Requires 2 to 4 weeks for therapeutic onset; not for immediate PRN use.

SSRI's Include

Sertraline (Zoloft) · Escitalopram (Lexapro) · Fluoxetine (Prozac)

SSRI's Considerations

First-line drug

Sexual Side effect common

Monitor for serotonin syndrome and increased suicidal ideation

Can't stop abruptly

SNRIs Include

Venlafaxine (Effexor XR) · Duloxetine (Cymbalta)

SNRIs Consideration

For GAD, PTSD, SAD

Monitor BP regularly] as it can increase BP

Taper slowly to discontinue; avoid abrupt stop

Buspirone Considerations

Non-Addictive, Non-Sedative, No benzo cross-tolerance

NOT PRN -- used to manage anxiety long-term

Hydroxyzine and Others includes [+ their purpose]

Hydroxyzine: Antihistamine + anxiolytic; non-addictive; PRN

Pregabalin: Adjunct for some GAD cases

Prazosin: Reduces trauma nightmares in PTSD

Beta-Blockers Considerations

Reduces peripheral SNS symptoms: palpitations, tremor

Used for performance/situational anxiety

Does not treat the psychological component

PRN for performance anxiety — NOT chronic use

Benzodiazepine Drugs

Lorazepam · Diazepam · Alprazolam

Benzodiazepine Considerations

Rapid onset — useful PRN in acute panic

High addiction/dependence risk, puts patient at fall risk

Can cause CNS depression

NEVER combine with alcohol or opioids

Taper to discontinue (D/C) as abrupt stop = seizure risk

Comprehensive Nursing Assessment for Anxiety Disorders

MSE, Priority, Standardization Test, ADLs, and rule out medical cause

Nursing Stepped Approach for Anxiety Disorder

1. Establish Safety and Trust

2. Reduce Stimuli

3. Teach Coping Skills

4. Medication Education

5. Discharge and Community Planning

Evidence-Based Treatments for Anxiety and Stress Related Disorders

CBT (Gold Standard), Exposure Therapy, Mindfulness, EMDR (Eye Movement Desensitization and Reprocessing), Relaxation

Trauma-Informed Care Core Shift

Shifting clinical focus from 'What is wrong with you?' to 'What happened to you?'

MSE

Assess appearance, behavior, affect and mood, thought process/content, cognition, insight, and judgement; Used structured and observed components; Note any anxious affect, psychomotor agitation, or thought racing

Priority

Assess for suicidal ideation, self-harm behaviors, and substance use; Alcohol and benzodiazepines are common as self-meds; Ask directly and always document response

Standardized

Look at scores and trend over time and correlate them with clinical presentation

Standardization includes

GAD-7 (GAD), PCL-5 (PTSD), Y-BOCS (OCD), PDSS (Panic Disorder)

What require clinical action

If GAD-7 is greater than or equal to 10 OR PCL-5 is greater than or equal to 33

ADLs

How many hours/days are consumed by the symptoms? Is client housebound? Are avoidance behaviors present?; Look for quantify impairment, not just presence of it

Rule Out Medical Cause

Vitals = increased HR, BP, RR; diaphoresis, tremors. Rule out caffeine/stimulant use, med side effects, thyroid disorders, or cardiac arrhythmias

Six Core Principles of Trauma-Informed Care

Safet, Trustworthiness and Transparency, Peer Support, Collabs and Mutuality. Empowerment + Voice + and Choice, Cultural + Historical and Gender Issues

Signs of Compassion Fatigue

Emotional exhaustion, cynicism, reduced empathy, intrusive thoughts about patients, avoidance of certain patients, and declining job satisfaction are key warning signals.

Compassion Fatigue Self-Assessment Tools

ProQOL (Professional Quality of Life Scale) measures compassion satisfaction, burnout, and secondary traumatic stress