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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