Anxiety Disorders

Anxiety

A vague feeling of apprehension, fear & doom that is accompanied by feelings of uncertainty and helplessness

Stress

A disequilibrium in the emotional and/or physical state which requires adaptation.

• Can be real or imagined.

• Individualized

Coping Skills Defined

Are conscious (mostly) actions taken to reduce anxiety and stress

Defense Mechanism Defined

Are unconscious (mostly) mental processes used to reduce anxiety and stress

Coping Skills and Defense Mechanism

Can be healthy or unhealthy

Unhealthy coping skills and defense mechanisms

Distorts reality and impairs problem solving which leads to maladaptive behaviors

Anxiety Disorders Contributing Factors

• Conflict occurs between the id and the superego

• Faulty, distorted, or counterproductive thinking patterns accompany or precede maladaptive behaviors and emotional disorders

• Neurotransmitter norepinephrine hyperarousal

• Physiological: Neurochemical reaction centered on the hypothalamic-pituitary-adrenal axis. (Fight or flight response).

• Chemical: caffeine, alcohol, illegal drugs, OTC meds.

Anxiety Disorders Classification

Panic Disorder

Phobias

Obsessive Compulsive Disorder

General Anxiety Disorder

Post-traumatic Stress Disorder

Somatoform Disorders

Dissociative Disorders

Somatoform Disorders

• Conversion Disorder

• Hypochodriasis

• Somatization Disorder/ Pain Disorders

• Body Dysmorphic Disorder

• Sleep Disorders

Dissociative Disorders

• Dissociative Amnesia/ Fugue

• Dissociative Identity Disorder

• Depersonalization Disorder

Anxiety Occurrence

When normal coping skills are unable to adequately deal with stress

Anxiety Disorder Occurrence

Anxiety disorders can result from chronic inadequate responses to multiple stresses or from one overwhelming stress

Anxiety Transmission

Nurses should monitor their own feelings

Coping Skills

• Avoidance

• Emotion Focused

• Problem Focused

Avoidance Focused Coping Skills

• Withdraw

• Sleep

• Daydream

Emotion Focused Coping Skills

• Pray

• Eat, drink & smoke

• Exercise

• Seek comfort from others

• Meditate & do yoga

• Take a bath

• Make a joke

• Cry

• Watch TV or go to a movie

• Drive

Problem Focused Coping Skills

• Seek advice

• Get another’s perspective

• Learn new information/skill

• Make goals

• Ask for help

• Do research & get information

• Delegate responsibilities

• Seek alternatives

• Brainstorm ideas

• Draw on past experiences

• Develop new resources

Defense Mechanism

• Compensation

• Conversion

• Denial

• Displacement

• Dissociation

• Fantasy

• Intellectualization

• Regression

• Rationalization

• Repression

• Somatization

• Suppression

Primary Gains

The anxiety is temporarily decreased, even when the behavior is maladaptive

Secondary Gains

Occur when there are additional benefits from the anxiety disorder such as increased attention and reduced responsibilities

Primary & Secondary Gains

Reinforce the anxiety disorder

Mild Anxiety

Increase in alertness, problem-solving, perception, concentration muscle tenseness & irritability

Moderate Anxiety

Selective inattention, narrowed perceptual field, problem solving diminished speech rapid and loud, restlessness

Severe Anxiety

Perception disjointed, minimal problem solving, poor concentration, hand wringing, crying, feeling overwhelmed

Panic Anxiety

Irrational, out of contact with environment, limited communication, agitated or immobilized, impulsive, severe emotional distress

Anxiety Nursing Diagnoses/Problems

• Altered thought process

• Impaired social interaction

• Impaired verbal communication

• Ineffective role performance

• Spiritual distress

• Disturbed sensory perception

• Hopelessness or Powerlessness

• Confusion acute

• Anxiety or Fear

• Impaired physical mobility

• Disturbed sleep patterns

• Self-care deficit

• Ineffective coping or Defensive coping

• Risk for injury

• Risk for violence self or other directed

Severe-Panic Anxiety Goals

• Not harm self or others.

• State a decrease in anxiety level

• Demonstrate improved role performance

• Experience fewer physiological manifestations of anxiety

Low Level Anxiety Interventions

Teach Anxiety Reducing Strategies:

• Distraction

• Guided imagery

• Deep breathing

• Progressive muscle relaxation

• Biofeedback

• Meditation

• Yoga

• Physical exercise

• Cognitive restructuring

Severe or Panic Anxiety Interventions

• Reducing environmental stimuli

• Speaking in short simple phrases

• Using touch judiciously

• Finding safe outlet for nervous energy

• Increasing supervision

• Administering anti-anxiety agent

Goal with these is to reduce anxiety and keep the patient safe

Anxiety Evaluation

• Would be directed to seeing if anxiety level was reduced

• Patient learned new coping skills, patient was kept safe

Panic Disorder Definition/Overview

Recurrent unpredictable episodes of extreme anxiety that last a few minutes but feel long for the patients

• Seen more in women

• Average onset about late 20’s

Overall Anxiety Disorders Risk Factors (Minus Phobias/OCD)

• Cognitive distortions

• Neurobiochemical or endocrine imbalances

• Overuse or ineffective coping/defense mechanisms

Panic Disorders Clinical Manifestations

• Unpredictable attacks of panic level

• Palpitations & chest pain

• Sweating & hot flashes

• Chills

• Shaking & parethesia

• SOB & choking feelings

• Dizziness

• Nausea

• Depersonalization

• Sense of impending doom, & fear of going crazy

Panic Attacks Nursing Diagnoses/Problems

• Panic anxiety & fear

• Ineffective individual coping

• Powerlessness & hopelessness

• Altered role performance

• Low self-esteem

Patient may present with possible physiological clinical manifestations

Panic Attack Goals

• Patient will report worrying less about having panic attacks

• Patient will have fewer panic attacks.

• Patient’s panic attacks will interfere less in patient’s ability to function.

• Patient uses methods to reduce anxiety before attacks and post-attack.

Panic Disorder Interventions

During an attack :

• Reduce environmental stimuli

• Speak in short simple phrases

• Use touch judiciously

• Stay with patient

• Administer anti-anxiety agent

Teach relaxation exercises, use cognitive restructuring about fears regarding having an attack

Panic Disorders Evaluation

• Patient reports worrying less about having panic attacks

• Patient has fewer panic attacks.

• Patient’s panic attacks interfere less in patient’s ability to function.

• Patient uses methods to reduce anxiety before and during attacks.

General Anxiety Disorder Definition/Overview

Chronic excessive fear and worrying

• Seen more in women

• Children and teens can be affected

General Anxiety Disorder Clinical Manifestations

• Excessive unrealistic worrying

• Irritability

• Muscle tension & fatigue

• Sleep and eating disturbances

General Anxiety Disorder Diagnoses/Problems

• Anxiety and fear

• Ineffective individual coping

• Powerlessness & hopelessness

• Altered role performance

• Disturbed sleep patterns

• Imbalanced nutrition

• Low self-esteem

Generalized Anxiety Disorder Goals

• Patient will report limited time spent worrying.

• Patient’s worrying will interfere less in patient’s ability to function.

• Patient will identify methods to reduce anxiety.

• Patient will report fewer cognitive distortions and negative self-talk.

Generalized Anxiety Disorders Interventions

• Teach relaxation exercises

• Use cognitive restructuring about fears, worries and capabilities

• Set aside worry time each day and stop worrying at other times

• Set aside worry place

• Address sleep and eating issues

Generalized Anxiety Disorder Evaluation

• Patient reports limited time spent worrying.

• Patient’s worrying interferes less in patient’s ability to function.

• Patient uses methods to reduce anxiety.

• Patient reports fewer cognitive distortions and negative self-talk.

Phobias Definition/Overview

Irrational fear--out of proportion to stimulus

• Social Phobia: fear of doing something in public such as public speaking, eating, using a restroom

• Specific Phobia: fear of a specific object or situation

• Mostly women (80%)

• Onset usually during adolescence

• Usually chronic with exacerbations, during times of increased stress

Social Phobia

Fear of doing something in public such as public speaking, eating, using a restroom

Specific Phobia

Fear of a specific object or situation

Phobias/Obsessive Compulsive Disorder Risk Factors

• Neurobiochemical imbalance

• Learned response

• Projection, displacement, sublimation of anxiety

• Unconscious conflict

Phobias Clinical Manifestations

• Subjective feeling of fear and anxiety triggers physiologic fight-or-flight AND response

• Behavioral steps to avoid or escape phobic stimulus

Phobias Nursing Diagnoses/Problems

• Anxiety and fear

• Ineffective individual coping

• Powerlessness

• Altered role performance

• Impaired social interaction

Phobias Nursing Goals

• Patient will have decrease exaggerated response to phobic stimulus.

• Phobia will interfere less in patient’s ability to function.

• Patient will identify methods to reduce anxiety.

Many people have phobias. Most will only seek help when behavioral steps impact too greatly on role performance and quality of life.

Phobias Nursing Interventions

• Antidepressant medications for chronic phobias

• Anti-anxiety medications for short term use only agent

• Cognitive restructuring of phobic situation/stimulation

• Behavioral modification: systematic desensitization, flooding

• Relaxation techniques: guided imagery, deep breathing, progressive muscle relaxation

Phobias Nursing Evaluation

• Patient has decreased exaggerated response to phobic stimulus.

• Phobia interferes less in patient’s ability to function.

• Patient identifies and uses methods to reduce anxiety.

Obsessive Compulsive Disorder Definition

• Obsession—intrusive persistent thoughts

• Compulsion--unwanted repetitive behaviors

Obsessive Compulsive Disorder Clinical Manifestations

• Ritualistic behaviors such as hand washing, counting, checking locks

• Behaviors usually increase during times of stress

• Obsessive thinking: Intrusive repetitive thoughts

Many people have OCD traits. Most will only seek help when it impacts too greatly on role performance and quality of life. They are aware that their behaviors are irrational but cannot stop

Obsessive Compulsive Disorder Nursing Diagnoses/Problems

• Anxiety and ineffective individual coping

• Powerlessness

• Altered role performance

• Impaired social interaction

Obsessive Compulsive Disorder Goals

• Patient will have decrease amount of ritualistic behavior.

• Patient will report decreased obsessive thinking.

• OCD will interfere less in patient’s ability to function.

• Patient will identify methods to reduce anxiety.

Obsessive Compulsive Disorder Nursing Interventions

• Do not stop ritual unless it is harming patient (then set limits)

• Allow time to do ritual

• Try to gradually have patient decrease ritual time and increase interval between ritualistic behavior

• Provide nonjudgmental feedback on behavior an its effects

• Do not punish for performing ritual

• Focus on triggers and underlying feelings

• Distract with diversional activities

• Antidepressant medications

• Positively reinforce non-ritualistic behaviors

• Safe structured environment

• Teach relaxation techniques (see phobias)

Obsessive Compulsive Disorder Evaluation

• Patient has decrease amount of ritualistic behavior.

• Patient reports decreased obsessive thinking.

• Patient OCD interferes less in ability to function.

• Patient identifies and uses methods to reduce anxiety.

Somatoform Disorders Definition/Overview

Anxiety & depression are converted into physical concerns and symptoms. These disorders are different

• Assessment must include thorough medical work-up

• Treatment includes hypnosis, psychotherapy, behavior modification, safe supportive environment, focus on feelings and current life stressors—not on symptoms

Conversion Disorder

Loss of motor or sensory function without physiologic basis La Belle Indifference: patient appears unconcerned about loss of function

Hypochodriasis

Unrealistic concerns over health; fears illness

Somatization Disorder/Pain Disorders

Multiple physical complaints without physiologic basis

Body Dysmorphic Disorder

Exaggerated belief that body is deformed

Sleep Disorders

Insomnia, hypersomnia, nightmares, sleepwalking (May have additional stresses such as shift work or medications) extremely common

Anxiolytics (Anti-anxiety) Uses

• Short term (not chronic) anxiety adaptations

• Short term agitation

• Alcohol withdrawal

• Non-psychiatric uses include:

  • Anti-seizure

  • Muscle relaxation

  • Pre-operative sedation

Anxiolytics (Non-psychiatric Uses)

• Anti-seizure

• Muscle relaxation

• Pre-operative sedation

Anxiolytics (Benzodiazepines)

• diazepam (Valium)

• Alprazolam (Xanax)

• clonazepam (Klonopin)

• lorazepam (Ativan)

• chlordiazepoxide (Librium)

These medications may have paradoxical effects in elderly and may remain active longer

Valium (Benzodiazepines)

diazepam

Xanax (Benzodiazepines)

alprazolam

Klonopin (Benzodiazepines)

clonazepam

Ativan (Benzodiazepines)

lorazepam

Librium (Benzodiazepines)

chlordiazepoxide

Anxiolytics (Benzodiazepines) Side Effects

• Drowsiness

• Loss of coordination

• Tiredness and mental slowing or confusion

• Tolerance and physical and psychological dependency occurs

• Abrupt withdrawal can cause seizures & psychosis

Anxiolytics (Anti-histamine)

• Hydroxyzine (Vistaril, Atarax)

• Diphenhydramine (Benadryl)

Hydroxyzine (Anti-histamine)

Vistaril and Atarax

Diphenhydramine (Anti-histamine)

Benadryl

Anxiolytics (Anti-histamine side effects)

• Dry mouth,

• Blurred vision,

• Orthostatic hypotension,

• Nausea,

• Constipation,

• Urinary retention,

• Confusion,

• Tachycardia

buspirone (Buspar)

Used for mild anxiety, less effective with serious anxiety

• Must be taken consistently for at least two weeks before getting better.

• Cannot be used as an as-needed basis.

• Prevents anxiety produced physical symptoms from developing

• Treats Generalized Anxiety Disorder

• Fewer tolerance and dependency problems

Buspar (buspirone) Side Effects

• Tiredness

• Stomachache

• Vomiting

• Constipation

• Diarrhea

• Headache

• Dry mouth

• Depression

• Excitement

• Trouble sleeping

• Lightheadedness

Dissociative Disorders Definition/Overview

Disturbances in the normally well-integrated continuum of consciousness, memory, identity and perception. Dissociation is an unconscious defense mechanism protecting against overwhelming anxiety

Includes:

• Amnesiac states such as dissociative amnesia and dissociative fugue

• Dissociative Identity Disorder (DID) formerly known as multiple personality disorder