Anxiety Disorders

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80 Terms

1

Anxiety

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

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2

Stress

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

  • Can be real or imagined.

  • Individualized

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Coping Skills Defined

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

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Defense Mechanism Defined

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

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Coping Skills and Defense Mechanism

Can be healthy or unhealthy

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Unhealthy coping skills and defense mechanisms

Distorts reality and impairs problem solving which leads to maladaptive behaviors

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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.

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Anxiety Disorders Classification

Panic Disorder

Phobias

Obsessive Compulsive Disorder

General Anxiety Disorder

Post-traumatic Stress Disorder

Somatoform Disorders

Dissociative Disorders

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Somatoform Disorders

  • Conversion Disorder

  • Hypochodriasis

  • Somatization Disorder/ Pain Disorders

  • Body Dysmorphic Disorder

  • Sleep Disorders

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Dissociative Disorders

  • Dissociative Amnesia/ Fugue

  • Dissociative Identity Disorder

  • Depersonalization Disorder

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Anxiety Occurrence

When normal coping skills are unable to adequately deal with stress

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Anxiety Disorder Occurrence

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

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Anxiety Transmission

Nurses should monitor their own feelings

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Coping Skills

  • Avoidance

  • Emotion Focused

  • Problem Focused

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Avoidance Focused Coping Skills

  • Withdraw

  • Sleep

  • Daydream

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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

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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

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Defense Mechanism

  • Compensation

  • Conversion

  • Denial

  • Displacement

  • Dissociation

  • Fantasy

  • Intellectualization

  • Regression

  • Rationalization

  • Repression

  • Somatization

  • Suppression

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Primary Gains

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

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Secondary Gains

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

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Primary & Secondary Gains

Reinforce the anxiety disorder

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Mild Anxiety

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

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Moderate Anxiety

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

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Severe Anxiety

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

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Panic Anxiety

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

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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

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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

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Low Level Anxiety Interventions

Teach Anxiety Reducing Strategies:

  • Distraction

  • Guided imagery

  • Deep breathing

  • Progressive muscle relaxation

  • Biofeedback

  • Meditation

  • Yoga

  • Physical exercise

  • Cognitive restructuring

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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

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Anxiety Evaluation

  • Would be directed to seeing if anxiety level was reduced

  • Patient learned new coping skills, patient was kept safe

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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

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Overall Anxiety Disorders Risk Factors (Minus Phobias/OCD)

  • Cognitive distortions

  • Neurobiochemical or endocrine imbalances

  • Overuse or ineffective coping/defense mechanisms

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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

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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

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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.

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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

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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.

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General Anxiety Disorder Definition/Overview

Chronic excessive fear and worrying

  • Seen more in women

  • Children and teens can be affected

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General Anxiety Disorder Clinical Manifestations

  • Excessive unrealistic worrying

  • Irritability

  • Muscle tension & fatigue

  • Sleep and eating disturbances

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General Anxiety Disorder Diagnoses/Problems

  • Anxiety and fear

  • Ineffective individual coping

  • Powerlessness & hopelessness

  • Altered role performance

  • Disturbed sleep patterns

  • Imbalanced nutrition

  • Low self-esteem

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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.

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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

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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.

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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

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Social Phobia

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

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Specific Phobia

Fear of a specific object or situation

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Phobias/Obsessive Compulsive Disorder Risk Factors

  • Neurobiochemical imbalance

  • Learned response

  • Projection, displacement, sublimation of anxiety

  • Unconscious conflict

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Phobias Clinical Manifestations

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

  • Behavioral steps to avoid or escape phobic stimulus

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Phobias Nursing Diagnoses/Problems

  • Anxiety and fear

  • Ineffective individual coping

  • Powerlessness

  • Altered role performance

  • Impaired social interaction

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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.

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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

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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.

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Obsessive Compulsive Disorder Definition

  • Obsession—intrusive persistent thoughts

  • Compulsion--unwanted repetitive behaviors

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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

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Obsessive Compulsive Disorder Nursing Diagnoses/Problems

  • Anxiety and ineffective individual coping

  • Powerlessness

  • Altered role performance

  • Impaired social interaction

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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.

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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)

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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.

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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

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Conversion Disorder

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

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Hypochodriasis

Unrealistic concerns over health; fears illness

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Somatization Disorder/Pain Disorders

Multiple physical complaints without physiologic basis

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Body Dysmorphic Disorder

Exaggerated belief that body is deformed

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Sleep Disorders

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

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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

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Anxiolytics (Non-psychiatric Uses)

  • Anti-seizure

  • Muscle relaxation

  • Pre-operative sedation

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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

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Valium (Benzodiazepines)

diazepam

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Xanax (Benzodiazepines)

alprazolam

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Klonopin (Benzodiazepines)

clonazepam

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Ativan (Benzodiazepines)

lorazepam

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Librium (Benzodiazepines)

chlordiazepoxide

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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

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Anxiolytics (Anti-histamine)

  • Hydroxyzine (Vistaril, Atarax)

  • Diphenhydramine (Benadryl)

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Hydroxyzine (Anti-histamine)

Vistaril and Atarax

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Diphenhydramine (Anti-histamine)

Benadryl

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Anxiolytics (Anti-histamine side effects)

  • Dry mouth,

  • Blurred vision,

  • Orthostatic hypotension,

  • Nausea,

  • Constipation,

  • Urinary retention,

  • Confusion,

  • Tachycardia

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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

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Buspar (buspirone) Side Effects

  • Tiredness

  • Stomachache

  • Vomiting

  • Constipation

  • Diarrhea

  • Headache

  • Dry mouth

  • Depression

  • Excitement

  • Trouble sleeping

  • Lightheadedness

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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

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