Anxiety disorders PTSD

EUSTRESS

BENEFICIAL STRESS; MOTIVATES PEOPLE

DISTRESS

CAUSES EMOTIONAL AND PHYSICAL PROBLEMS; COULD RESULT IN DEPRESSION, CONFUSION, HOPELESSNESS/HELPLESSNESS, FATIGUE, ETC

Stress response

• fight or flight

• survival mechanism

Neurobiology

LIMBIC SYSTEM: “EMOTIONAL BRAIN”; MADE UP OF

AMYGDALA, HIPPOCAMPUS, THALAMUS, HYPOTHALAMUS,

BASAL GANGLIA, AND CINGULATE GYRUS

• THREE FUNCTIONS:

• 1. SCAN ENVIRONMENT FOR THREAT

• 2. INITIATE BODY’S READINESS BY ELICITING FIGHT-OR-

FLIGHT RESPONSE

• 3. TERMINATE REACTIVITY AFTER STRESSOR SUBSIDES TO

RESTORE HOMEOSTASIS

Neurotransmitters involved in Anxiety

SEROTONIN: THOUGHT TO BE DECREASED IN ANXIETY

DISORDERS; SSRIS OFTEN CONSIDERED A FIRST-LINE

PHARMACOLOGIC INTERVENTION

• NOREPINEPHRINE: INCREASES WHEN PERSON FEELS

THREATENED AND CAN CAUSE HYPERAROUSAL; MEDS

LIKE PROPRANOLOL CAN BLOCK THIS ACTIVITY

• GABA: INHIBITORY NEUROTRANSMITTER; SLOWS

NEUROTRANSMISSION, WHICH HAS A CALMING EFFECT

Prolonged Stress

BODY REMAINS IN “HIGH ALERT,” AND CORTISOL AND

ADRENALINE STAY IN BODY, WHICH CAN HAVE NEGATIVE

EFFECTS ON THE BODY

Anxiety

APPREHENSION OR UNEASINESS FROM A REAL

OR PERCEIVED THREAT WHERE THE SOURCE IS

UNKNOWN/UNRECOGNIZED

Fear

fight or flight response to a specefic danger

Normal anxiety

healthy, productive

acute anxiety

loss or threat to sense of security; an expected response

Pathological

maladaptive-greater in duration, intensity and impact on persons functioning

DEFENSE MECHANISMS

(FREUD)

MEANS OF MANAGING CONFLICT AND AFFECT

• USUALLY UNCONSCIOUS

• DISCRETE FROM ONE ANOTHER

• MAY SIGNIFY PSYCHIATRIC ILLNESSES, BUT ARE

REVERSIBLE

• ADAPTIVE AS WELL AS PATHOLOGICAL

• TYPICALLY, FREQUENCY, DURATION, AND INTENSITY

DICTATE WHETHER USE IS ADAPTIVE OR MALADAPTIVE

examples of defense mechanism

• ALTRUISM

• SUBLIMATION

• HUMOR

• SUPPRESSION

• REPRESSION

• DISPLACEMENT

• REACTION FORMATION

• SOMATIZATION

• UNDOING

• RATIONALIZATION

• PASSIVE AGGRESSION

• ACTING-OUT

• DISSOCIATION

• DEVALUATION

• IDEALIZATION

• SPLITTING

• PROJECTION

• DENIAL

SUBLIMATION

is a defense mechanism involving the channeling of unacceptable impulses into socially acceptable behaviors or activities, allowing for personal growth and expression.

REACTION FORMATION

is a defense mechanism that involves converting unacceptable feelings or impulses into their opposites, often leading to exaggerated behaviors that reflect those opposite feelings.

UNDOING

is a defense mechanism that involves attempting to reverse or negate a thought, feeling, or action that one finds distressing, often through acts of kindness or reparative behavior.

devaluation

is a defense mechanism where a person attributes exaggeratedly negative qualities to self or others, reducing their perceived value, often to cope with feelings of insecurity or inadequacy.

suppression

is a defense mechanism involving consciously pushing distressing thoughts, feelings, or memories out of awareness, aiming to reduce anxiety and promote emotional stability.

repression

is a defense mechanism that involves unconsciously blocking distressing thoughts, feelings, or memories from awareness, often to protect oneself from emotional pain.

Rationalization

is a defense mechanism that involves offering reasonable explanations for behaviors or actions that are otherwise anxiety-provoking, often to avoid facing uncomfortable feelings or realities.

THEORIES REGARDING ANXIETY

• LEARNING THEORIES: ANXIETY IS A LEARNED RESPONSE;

• E.G., WE LEARN TO BE FEARFUL BASED ON HOW WE SEE OTHERS RESPOND TO A THREAT

• THUS, WE CAN LEARN NOT TO BE FEARFUL IN SITUATIONS THROUGH GRADUAL EXPOSURE

• COGNITIVE THEORIES: ANXIETY DISORDERS RESULT

• FROM DISTORTIONS IN THINKING AND PERCEPTION

• REFRAMING THINKING CAN LITERALLY CHANGE BRAIN

• CHEMISTRY

Levels of Anxiety

Mild:

Moderate

Severe

Panic

Mild Anxiety Signs and symptoms

Can be seen in normal functioning. ABLE TO

SEE/HEAR/GRASP MORE INFORMATION, PROBLEM SOLVING MORE EFFECTIVE

Moderate levels of anxiety

LESS THAN OPTIMAL ABILITY TO LEARN AND

PROBLEM-SOLVE; MAY ONLY SEE/HEAR CERTAIN THINGS IN

THE ENVIRONMENT. POSSIBLY STILL ABLE TO BE

CONSTRUCTIVE

Severe Anxiety Signs and symptoms

PERCEPTUAL FIELD GREATLY REDUCED; LEARNING

AND PROBLEM-SOLVING NOT POSSIBLE

Panic Signs and Symptoms

Most severe; unable to process environment and may lose touch with reality

Mild to Moderate Anxiety Interventions

Employ open-ended questions, give braod openings and seek clairification

•Restricting topics and talking about irrelevant topics can increase the patient’s anxiety

•Stay calm! Be willing to listen

Severe to panic level anxiety interventions

•unable to problem solve, behaviors may be unproductive; regression is common

•Firm, short and simple statements most effective

Theories Regarding Anxiety

Learning theories: anxiety is a learned response; e.g., we learn to be fearful based on how we see others respond to a threat

Thus, we can learn not to be fearful in situations through gradual exposure

Cognitive theories: anxiety disorders result from distortions in thinking and perception

Reframing thinking can literally change brain chemistry

Common Patient Problem

•Anxiety

•Determine level of anxiety

•Impaired coping

•Implications for work, school, relationships, functioning

•Knowledge/patient education

•Coping skills

•Anxiety reduction

•Problem solving skills

•Community resources/support groups

•Issues with sleep---insomnia

•Sleep hygiene protocols and education

Four Cardinal Symptoms of PTSD

• Intrusive reexperiencing of the initial trauma

• avoidance

• Persistent negative alterations in cognitions and mood

• alteration and arousal activity

Intrusive reexperiencing of the initial trauma (ptsd sign 1)

•(flashbacks, nightmares, unwanted memories that are distressing, and feelings of unreality

Avoidance (PTSD Sign 2)

Avoidance (avoid memories and feelings as well as places or people that remind person of event)

Persistent negative alterations in cognitions and mood (PTSD Sign 3)

(feelings of detachment, cognitive distortions about themselves or others)

Alteration and arousal activity (PTSD 4)

(irritability, anger outbursts, self-destructive behavior, hypervigilance, exaggerated startle response, sleep disturbances)

PTSD Nursing Interventions

•Nursing problem: Posttrauma Syndrome

•assess for SI/HI, anxiety level, substance use

•assess that physical symptoms are not due to physical cause (dizziness, headaches, etc.)

•avoid minimizing trauma

•teach cognitive and behavioral techniques to manage symptoms of emotional or physical reactivity

•

PTSD GOALS/OUTCOMES of treatment

•Patient and others (family, friends) will feel safe

•Patient will receive treatment for co-occurring conditions (e.g. substance abuse, depression, anxiety)

•Patient will attend support groups

•Patient will expand social support

•Patient will experience increase in restful sleep with fewer nightmares and flashbacks

•Patient will express decreased irritability

•Patient will effectively demonstrate anxiety reduction techniques

Acute Stress Disorder

Can occur after same types of events as those that trigger PTSD

Difference is that symptom resolution occurs within a month

May require short-term medications to manage symptoms of anxiety and insomnia

Difference between Acute Stress Disorder and PTSD

Acute Stress resolve within a month

Secondary Stress/Compassion Fatigue

Differs from burnout, which is related to emotional distress and withdrawal as a result of increased workload and occupational stressors

Secondary traumatic stress and compassion fatigue are used interchangeably-emotional effect that nurses and other health care workers experience as a result of being indirectly traumatized through attempting to help those who have experienced trauma

Symptoms of compassion fatigue

Feeling overwhelmed, exhausted physically and mentally

Unable to function effectively

Intrusive thoughts

Difficulty separating self from work

Pessimism, short temper

Feelings of dread

Depression

Inability to effectively use coping mechanisms

Social withdrawal

Sleep issues

Decreased self-esteem

Hopelessness

Self-doubt; questioning one’s competence

Those of high risk of secondary trauma/compassion fatigue

Hospice care

Pediatrics

Emergency departments

Oncology

Forensic nursing

Psychiatric nurses

Social workers

anxiety disorders

• Can be a symptom of a medical condition, or can mimic a physical ailment

Anxiety is an expected reaction to threatening situations

•Everyone experiences occasional distress

•Problematic when interferes with adaptive behavior, causes physical symptoms, or exceeds what is tolerable to individual

•Causes dysfunction at work and in social settings, and impacts relationships

Separation Anxiety Disorder

Developmentally inappropriate level of concern about being away from a significant other

Typically diagnosed before age 18 after a month of symptoms, but adults can have/develop too

Creates relationship strain

The most common anxiety disorder in children

The fear, anxiety, or avoidance is persistent, lasting at least 4 weeks in children and adolescents and typically 6 months or more in adults.

Separation anxiety: Nursing interventions

•Identify and acknowledge specific fears

•Desensitization

•Medications (SSRIs, Benzodiazepines) in early stages

Panic Disorders

Panic attack is key feature of panic disorders

Sudden onset of extreme apprehension or fear; feelings of impending doom

Occur suddenly, often without warning, and last generally 1-30 minutes

Can happen day or night

Perceptual field limited, normal function not possible, misinterpretation of reality

Physical symptoms: palpitations, chest pain, diaphoresis, muscle tension, urinary frequency, hyperventilation, breathing difficulties, nauseas, feelings of choking, chills, hot flashes, and GI symptoms

•At least one of the attacks has been followed by 1 month (or more) of one or both of the following:

•Persistent concern or worry about additional panic attacks or their consequences (e.g., losing control, having a heart attack, “going crazy”).

•A significant maladaptive change in behavior related to the attacks (e.g., behaviors designed to avoid having panic attacks, such as avoidance of exercise or unfamiliar situations).

Nursing Interventions for Panic Attack

• Provide a Safe, calm environment

• reassure the patient and listen actively

• encourage patient to talk about feelings and concerns

• use reframing techniques

• Identify negative self-talk

• refer to the appropriate services

• administer meds

Having a panic attack?

• 5 things you can see

• 4 things you can touch

• 3 things you can hear

• 2 things you can smell

• 1 thing you can taste

Phobias

Persistent, intense, irrational fear of a specific object, activity, or situation

Leads to desired or actual avoidance

Specific phobias: e.g., spiders, heights, storms, blood, closed spaces-very common

Behavioral therapy, rather than meds, is most effective for specific phobias

typically last for 6 months or more

Which therapy is most effective for phobias?

behavioral therapy is most effective for phobias.

common phobias

Clinical Name	Feared Object or Situation
Acrophobia	Heights
Agoraphobia	Open spaces
Astraphobia	Electrical storms
Claustrophobia	Closed spaces
Glossophobia	Talking
Hematophobia	Blood
Hydrophobia	Water
Monophobia	Being alone
Mysophobia	Germs or dirt
Nyctophobia	Darkness
Pyrophobia	Fire
Xenophobia	Strangers
Zoophobia	Animals

Social Anxiety Disorders(Social Phobias)

Anxiety or fear provoked by exposure to social situation or performance situation

Fear of humiliation or embarrassment

Deals with fear of being evaluated or rejected by others

Fear of public speaking: most common

Treatment of Social Anxiety Disorders (social phobias)

Treatment: Propranolol (reduces physiological symptoms, but not cognitive)

For more pervasive cases, SSRIs and MAOIs, CBT

Agoraphobia

Excessive anxiety about or fear of being in places or situations where help is not available, or where escape is difficult or embarrassing

DSM 5 diagnosis made when person experiences fear or anxiety in two situations

•Avoidance can be debilitating and impact quality of life-work, family, etc.

Nursing Interventions for Social Anxiety and Agoraphobia

Again, identify faulty thought patterns/distortions

• Systematic desensitization

• Flooding (implosion therapy)-not always appropriate

• Behavior therapy

General Anxiety Disorder (GAD)

Chronic, associated with severe distress

Pervasive difficulties in cognition and functioning

Often see poor health-related outcomes

Characterized by excessive, persistent, and uncontrollable anxiety, as well as excessive worrying

At least three of the following are present: restlessness, fatigue, poor concentration, irritability, muscle tension, and sleep disturbance.

Most occur for the better part for 6 months

GAD treatment

Treatment: SSRIs, SNRIs, Buspirone, CBT

Nursing Interventions For GAD

Encourage discussion about feelings/concerns

Ask clarification questions

Help patient identify thoughts/feelings that occur before onset of worry

Encourage problem solving

Role play/model

Explore behaviors that have been effective in the past

Identify cognitive distortions

Diagnostic Criteria GAD

At least three of the following are present:

• restlessness,

• fatigue,

• poor concentration,

• irritability,

• muscle tension, and

• sleep disturbance.

Most occur for the better part for 6 months

Anxiety due to Medical Conditions

•Direct physiological result of a medical condition

•Respiratory: asthma, hypoxia, pulmonary edema, COPD, pulmonary embolism

•Cardiovascular: cardiac dysrhythmias such as torsades de pointes, angina, CHF, mitral valve prolapse, HTN

•Endocrine: hyperthyroidism, hypoglycemia, hypercortisolism, pheochromocytoma

•Neurological: Parkinson’s disease, akathisia, postconcussion syndrome, complex partial seizures

•Metabolic: hypercalcemia, hyperkalemia, hyponatremia, porphyria

Obsessive-compulsive and Related Disorders

Obsessive-compulsive disorder (OCD): thought to be related to hyperactivity in the prefrontal cortex and dysfunction in basal ganglia and cingulum

Dysregulation of Serotonin

Obsessions: thoughts, impulses, or images that persist to an extent that they cannot be ignored by person experiencing them

Compulsions: ritualistic behaviors that a person feels compelled to perform in order to reduce anxiety

Almost always occur together, as in OCD diagnosis

Obsessions

thoughts, impulses, or images that persist to an extent that they cannot be ignored by person experiencing them

Compulsions

Ritualistic behaviors that a person feels compelled to perform in order to reduce anxiety

Nursing Interventions (OCD)

• Teach techniques that can distract and distance PT self from thoughts

• Gradually assist patient in reducing time spent in ritualistic behaviors

  • •Cognitive restructuring

    •Relaxation techniques

    •Modeling techniques

    •Behavior therapy

Body Dysmorphic Disorder

Sometimes have minor physical defects, but usually have a normal appearance

Preoccupation with imagined “defective” body part

Obsessive thinking about this; resulting compulsions (excessive grooming, picking, etc.)

Impairs social, academic, or occupational functioning

Body Dysmorphic Disorder treatment

Treatment: SSRIs, clomipramine (tricyclic), and CBT

Second generation antipsychotic added to SSRI may help in severe cases (if more delusional)

Hoarding

•Excessive collecting of items that are essentially worthless (but wealthy people may hoard more expensive items)

•Often feel shame related to behavior

•Impacts relationships with family and friends, as people may hoard so much that they isolate

•Compulsive hoarding does not meet criteria for OCD

Nursing Interventions for Hoarding Disorder

Assist in decision-making and categorizing

Cognitive restructuring

Behavioral exposure

Habituation to discarding

Medications may be helpful for anxiety and depression

Difficult to treat due to resistance to treatment, lack of insight, etc.

Trichotillomania Disorder and Excoriation Disorder

Trichotillomania (hair pulling)

Excoriation (skin picking)

Result in varying levels of disability, stigma, and altered appearance

People often try to hide activity

SSRIs most common form of treatment; with excoriation, may involve dermatologist as well (with psychiatric professionals)

Most common form of treatment for trichotillomania, or excoriation

•SSRIs most common form of treatment; with excoriation, may involve dermatologist as well (with psychiatric professionals)

Pharmacological Interventions for Anxiety

Benzos: short term

Buspirone

SNRIs(venlafaxine)

Tricyclin Antidepressants

MAOIs(recently used in ppl with sad)

Blood pressure Meds (Beta Blockers, alpha agonist)

Antihistamines (Hydroxyzine/Vistaril)

Combo meds:travil

Venlafaxine is the only FDA approved

SNRI for Panic disorder, GAD and SAD

Tricyclic Antidepressants are

2nd or 3rd line for anxiete

Treatment for PTSD

Meds-SSRIs, Clonidine, Prazosin

CBT

EMDR

Acupuncture, animals, yoga, etc.

CPT

Methylphenidate?

Treatment for Panic Disorders

• CBT

• SSRIs(Fluoxetine, sertraline, escitalopram)

• Tricyclics(amitriptyline, noritriptyline)

• MAOS( Phenelzine, tranylcypramine)

• Benzodiazepines(Alprazolam, clonazepam, lorezepam) SHORT TERM

Special consideration for Benzos

• Only short term treatment of anxiety

Benzos to know

Valium/Diazepam 
Ativan/Lorazepam 
Klonopin/Clonazepam 

Nursing Implications of Benzo

Promote activity of GABA

Sedative/hypnotic effects

Risk for tolerance/withdrawal

Risk for respiratory depression, coma, and death (especially in combination with other sedating medications)

Affects motor ability and judgment (risk for falls, impaired driving, etc.)

Medication/substance interactions (muscle relaxants, alcohol, allergy medications)

BENZODIAZEPINE WITHDRAWL SYMPTOMS

Possible symptoms:

Headache

Sweating

Dizziness

Shakiness/tremor

Nausea

Sleep disturbances

Anxiety

Poor concentration

Palpitations

Perceptual disturbances

Seizures (greatest risk)

SSRIs for anxiety (Panic, SAD, GAD)

• fluozetine

• sertraline

• paroxetine

Nursing Implications: SSRIs

uSSRIs inhibit reuptake of serotonin, increasing availability at the synapse

uCan actually result in anxiety

uOther side effects: sexual dysfunction, insomnia, GI disturbance, dizziness, drowsiness, increased risk for bleeding, SUICIDAL IDEATION!!

uPossibility of serotonin toxicity (e.g., Serotonin Syndrome)-more common if co-administered with other medications that impact Serotonin, or those that inhibit the CYP450 enzyme (Ketoconazole)

Serotonin Symptons

Hyperactivity or restlessness

Tachycardia

Fever

Elevated BP

Altered mental status

Irrationality, mood swings

Seizures

Myoclonus, incoordination

Abdominal pain, diarrhea

Apnea

Serotonin Syndrome

uD/C offending agent(s)

uSerotonin receptor blockade-cyproheptadine, propranolol

uCooling blankets (hyperthermia)

uDantrolene, Diazepam for muscle rigidity

uAnticonvulsants

Artificial ventilation

Nursing Implications Tricyclics

uAnticholinergic effects (dry mouth, blurred vision, tachycardia, constipation, reflux, urinary retention)

uPostural hypotension: increased risk for falls

uSedating effects

uCardiovascular adverse effects: dysrhythmias, tachycardia, MI, and heart block

uRisk for lethal overdose

uPatient teaching important

Nursing implications: Beta Blockers

• Nor risk for withdrawl, as with benzo

• avoid use with alcohol

• bradycardia, heart block, chf

  • Rare at lower anxiety doses

• Dizziness, fatigue, hypotension

• SJS

Buspar Side effects

EPS, Akathisia, nasuea, headache, fatigue, dizziness, drowsiness nausea

Buspar Nursing Implications

• Non Habit-forming;no risk for dependance

• less sedating, can drive/operate machinery more safely than with benzos

• BUSPAR IS NOT IMMEDIATE ACTING, MAY TAKE UP 2-4 WEEKS TO FEEL THE FULL BENEFIT

Nursing Implications: Alpha Agonists ADVERSE Side Effects

• Hypotension

• Syncope

• AV Block

• Headaches

• Dizziness

• Somnolence

Anticholinergic effects

(dry mouth, blurred vision, tachycardia, constipation, reflux, urinary retention)

CAM for anxiety

Kava Kava: thought initially to elevate mood, well-being, contentment, and relaxation. Now, thought to increase psychiatric symptoms

Valerian: used for anxiety, but also for insomnia

Safe for most people when used on a short-term basis; however, can cause headaches, excitability, uneasiness, and insomnia (ironic)