N260 Exam #2 Study Guide

Anxiety (12 Q’s)

• Anxiety: is an emotional response to anticipation of danger. It is not the same as stress. Anxiety becomes problematic when it becomes disabling that an individuals functioning on a daily basis is adversely affected.

Signs & Symptoms of Generalized Anxiety Disorder

• Generalized Anxiety Disorder (GAD): The presence of excessive anxiety and worry about a variety of topics, events, or activities

  • Worry occurs more often than not for at least 6 months and is clearly excessive

  • The worry is experienced as very challenging to control

    • The worry in both adults and children may easily shift from one topic to another

  • Symptoms:

    • Edginess or restlessness

    • Tiring easily; more fatigued than usual

    • Impaired concentration or feeling as though the mind goes blank

    • Irritability (may or may not be observed by others)

    • Increased muscle aches or soreness

    • Difficulty sleeping

    • “Caught in an endless loop”

• Similar to MDD, pts w/ GAD are so overwhelmed by the “anxiety loop” that they become irritable, indecisive, and lose motivation to participate in life

Defense Mechanisms of GAD

• Defense mechanisms serve to help the pt subconsciously distance themselves from unwanted feelings and prevent new unwanted ones from forming. Tension reduction is the overall goal of defense mechanisms. It is protective

• Projection is highlighted in your materials as an immature defense mechanism where:

  • A person unconsciously rejects emotionally unacceptable personal features

  • Attributes those unacceptable traits to other people, objects, or situations

  • Manifests as blaming, scapegoating, prejudicial thinking, and stigmatization

  • Can be associated with paranoia

  Example: People who always feel others are out to deceive or cheat them may be projecting their own characteristics that they find distasteful and cannot consciously accept.

  • Other defense mechanisms:

    • Conversion

    • Compensation

    • Denial

    • Displacement

    • Identification

    • Idealization

    • Intellectualization

    • Introjection

    • Isolation

    • Rationalization

    • Reaction formation

    • Regression

    • Repression

    • Splitting

    • Sublimation

    • Suppression

    • Undoing

Healthy Defenses

• Altruism → in altruism, emotional conflicts and stressors are addressed by meeting the needs of others. Unlike self-sacrificing behavior, in altruism, the person receives gratification either vicariously or from the response of others.

  • Six months after losing her husband in a car accident, Jeanette began to spend 1 day a week doing grief counseling with families who had lost a loved one. She found that she was effective in helping others in their grief, and she obtained a great deal of satisfaction and pleasure from helping others work through their pain.

• Humor → Humor makes life easier. An individual may deal with emotional conflicts or stressors by emphasizing the amusing or ironic aspects of the conflict or stressor through humor.

  • A man is interviewed for a job by the top executives of a company. He has recently had foot surgery, and on entering the interview room, he stumbles and loses his balance. There is a stunned silence, and then the man states calmly, “I was hoping I could put my best foot forward.” With everyone laughing, the interview continues in a relaxed manner.

• Suppression is the conscious denial of a disturbing situation or feeling.

  • A student who is studying for the state board examination says, “I can’t worry about paying my rent until after my exam tomorrow.”

GAD Outcomes

• Generalized anxiety disorder (GAD) is characterized by excessive anxiety and worry about a number of events and activities. People with GAD find it difficult to shake their concerns and report being unable to relax. It is sometimes referred to as the “worry disease” (What if I’m late? … What if I fail? … What if I am fired?). A diagnosis of GAD is made if at least three of the following symptoms are present: restlessness, fatigue, poor concentration, irritability, muscle tension, and sleep disturbance

• When planning care for patients with GAD, outcomes focus on reducing anxiety symptoms and improving coping abilities. Here are the key desired outcomes:

  Symptom Management Outcomes

  Reduced Anxiety Levels:

  • Decreased frequency and intensity of worry

  • Reduction in "what if" thinking patterns

  • Improved ability to control excessive worry

  • Decreased physical symptoms (muscle tension, fatigue, restlessness, sweating, nausea)

  Improved Cognitive Function:

  • Better concentration and focus

  • Enhanced decision-making ability

  • Reduced fear of making mistakes

  Functional Outcomes

  Effective Coping:

  • Patient demonstrates use of healthy coping strategies

  • Engages in stress-reduction techniques (breathing exercises, progressive muscle relaxation, guided imagery)

  • Practices positive self-talk and challenges negative thinking

  • Participates in support groups or therapy

  Daily Functioning:

  • Returns to normal activities of daily living

  • Maintains work/school performance

  • Sustains healthy relationships

  • Manages responsibilities effectively

  Behavioral Outcomes

  Active Participation in Treatment:

  • Engages in psychotherapy (CBT, ACT, or other evidence-based approaches)

  • Adheres to medication regimen if prescribed (SSRIs, buspirone)

  • Practices cognitive restructuring techniques

  • Uses relaxation and mindfulness strategies

  Family/Caregiver Outcomes:

  • Family members understand the condition

  • Support system is engaged in patient's care

  • Family demonstrates effective coping with patient's anxiety

  Timeline Considerations

  Outcomes may be short-term or long-term depending on:

  • Severity of symptoms

  • Patient's coping response

  • Nature of the stressor

  • Available support systems

  Remember: Coping with stress takes time. Ongoing communication and reassessment are essential to evaluate whether interventions are promoting adaptation and whether the patient's expectations are being met.

Nursing interventions for GAD

• Actively listen to the individual and encourage exploration of feelings

• Reassure individual about their safety

• Validate their feelings and concerns

• Explore alternative/new coping strategies

• Help acknowledge anxiety rather than deny or intellectualize it

• Assist in identifying behaviors that indicate individual is feeling anxious

• Assist pt w/ connecting anxiety w/ uncomfortable physical, emotional, or behavioral responses

• Discourage use of caffeine, alcohol, or drugs to “calm nerves”

• Provide information

• Teach the pt and family/significant others about anxiety disorders

• Educate pts about the signs and symptoms of the disorder

• Support treatment adherence

• Promote care of self including nutrition and sleep

• Access informatics that can provide patients w/ information and learning

Assessment of Anxiety/Recognizing Cues

• Assess and acknowledge presence of anxiety (behavioral and somatic symptoms)

• Assess pt’s perception of the situation

• Evaluate psychosocial stressors and developmental issues

• Assess for suicidal ideation, intent, and/or plan

• Conduct a head to toe assessment w/ vital signs

• Explore hx of mental illness or substance use

• Assess pt’s ability to focus and concentrate

• Observe and assess pt’s speech

• Assess current coping mechanisms

• Request labs including thyroid, function, blood, glucose, echo, tox screen

• GAD-7 screening tool

  • The Generalized Anxiety Disorder Scale-7 (GAD-7) is a validated screening instrument mentioned in your textbook materials for assessing anxiety disorders, particularly in perinatal populations.

    What is the GAD-7?

    The GAD-7 is a brief, 7-item self-report questionnaire that screens for the presence and severity of generalized anxiety disorder. It asks patients how often they've been bothered by anxiety symptoms over the past 2 weeks.

    Clinical Use

    Your textbook specifically mentions the GAD-7 as one of the screening tools for anxiety disorders in pregnant and postpartum women, alongside:

    • Edinburgh Postnatal Depression Scale (EPDS)

    • Perinatal Anxiety Screening Scale

    • Patient Health Questionnaire-9 (PHQ-9)

    Scoring & Interpretation

    The GAD-7 uses a 0-3 point scale for each item:

    • 0 = Not at all

    • 1 = Several days

    • 2 = More than half the days

    • 3 = Nearly every day

    Total scores range from 0-21:

    • 0-4: Minimal anxiety

    • 5-9: Mild anxiety

    • 10-14: Moderate anxiety

    • 15-21: Severe anxiety

    A score of 10 or higher typically warrants further evaluation and possible intervention.

    Symptoms Assessed

    The GAD-7 evaluates core GAD symptoms including:

    • Feeling nervous, anxious, or on edge

    • Not being able to stop or control worrying

    • Worrying too much about different things

    • Trouble relaxing

    • Being restless

    • Becoming easily annoyed or irritable

    • Feeling afraid something awful might happen

    Nursing Implications

    Positive screening results require:

    • Further comprehensive assessment

    • Appropriate referrals

    • Prompt treatment initiation

    • Follow-up screening to monitor progress

    The effectiveness of screening depends on proper follow-up for positive results to ensure patients receive needed care.

Phobias

• An irrational and disproportionate fear of an object or situation

  • Person is generally aware that the fear is unreasonable and excessive

  • Pts have overwhelming symptoms of panic when exposed to phobic stimulus. Remove the stimulus, the anxiety goes away.

• Diagnosis made only if avoidant behavior causes problems in functioning (occupational social relationships) or if pt is distressed about having the fear

• Cognitive Behavioral Therapy (CBT) is among the most evidence-based therapies for treating phobias, including social anxiety disorder and agoraphobia. CBT examines how negative thoughts contribute to anxiety and how individuals behave in situations that trigger fear.

  Key CBT Components:

  • Challenges cognitive distortions through cognitive restructuring

  • Teaches that our thoughts, not external events, affect how we feel

  • Helps identify "automatic" thoughts that trigger anxiety

  Acceptance and Commitment Therapy (ACT) is an action-oriented approach where patients:

  • Learn to accept distressing emotions as appropriate to certain situations

  • Commit to making behavioral changes despite anxiety

  • Has research support for treating social anxiety disorder

  Behavioral Therapy Techniques

  Behavioral therapies are based on the premise that all behaviors are learned and unhealthy behaviors can be unlearned. Common techniques include:

  Exposure Therapy - Gradual exposure to feared situations

  Relaxation Training:

  • Breathing exercises

  • Progressive muscle relaxation

  • Guided imagery

  • Meditation (helps enter a state of relaxation or restful alertness)

  Important Note: While relaxation techniques help reduce anxiety symptoms, there's no good evidence these techniques alone effectively treat phobias. They work best as components of other evidence-based behavioral therapies.

  Pharmacological Interventions

  Antidepressants (SSRIs):

  • Help reduce anxiety in phobias

  • Particularly effective for agoraphobia

  • Can treat comorbid depression

  Anxiolytics (Benzodiazepines):

  • May be used for short-term anxiety relief

  • Examples: diazepam, alprazolam

  Nursing Interventions

  Empowerment through education about:

  • The nature of phobias

  • Treatment options

  • Coping strategies

  Sensory interventions:

  • Music therapy

  • Aromatherapy

  Behavioral interventions combined with cognitive strategies like encouraging positive self-talk and questioning negative thinking

• Behavioral

  • Systemic desensitization

    • creation of graduate exposure to the fear of the stimuli. Encouraged to refrain from using avoidance response

  • Implosion

    • Bombarding or flooding the pt with an exaggerated version of the phobic stimuli

• Education → concept that phobias are learned behaviors that can be unlearned and discuss how new behaviors can be learned

Agoraphobia interventions

Psychotherapy (First-Line Treatment)

Cognitive Behavioral Therapy (CBT) is the most evidence-based treatment for agoraphobia. CBT helps patients:

• Identify and challenge cognitive distortions about feared situations

• Understand that thoughts, not external events, drive anxiety

• Restructure negative thinking patterns through cognitive restructuring

Exposure Therapy (a behavioral technique) is particularly effective for agoraphobia:

• Gradual, systematic exposure to feared situations (crowded places, public transportation, open spaces)

• Helps "unlearn" conditioned fear responses

• Based on the premise that unhealthy behaviors can be changed through new learning

Acceptance and Commitment Therapy (ACT):

• Teaches acceptance of distressing emotions in certain situations

• Focuses on committing to behavioral changes despite anxiety

• Action-oriented approach stemming from traditional CBT

Behavioral Techniques

Relaxation Training (used as adjuncts to therapy):

• Breathing exercises

• Progressive muscle relaxation

• Guided imagery

• Meditation for restful alertness

Important: These techniques help reduce symptoms but aren't effective alone—they must be combined with evidence-based therapies like CBT.

Pharmacological Treatment

Antidepressants (SSRIs/SNRIs):

• Most widely prescribed for long-term anxiety treatment

• Effective for agoraphobia

• Treat cooccurring depression

• Caution: Start with low doses due to activating effects that may temporarily increase anxiety

• Must be tapered slowly when discontinuing to prevent withdrawal syndrome

Anxiolytics (Benzodiazepines):

• Short-term anxiety relief only

• Examples: diazepam, alprazolam

• Not recommended for long-term use

Nursing Interventions

• Education: Empower patients with knowledge about agoraphobia and treatment options

• Encourage positive self-talk and questioning negative thinking

• Sensory interventions: Music therapy, aromatherapy

• Support therapy adherence and practice of coping skills

• Monitor medication response and side effects

Combined Approach

Psychotherapy and pharmacotherapy are frequently used together for optimal outcomes, especially when patients have barriers to accessing therapy alone.

Panic attack

• Recognize the signs

• Remain calm

• Stay with the pt

• Don’t make assumptions about what the person needs

• Speak to the person in short simple sentences using a soothing voice

  • “I am here for you”

  • “I won’t leave”

  • “It won’t last long”

  • “You are safe”

• Avoid repeating saying things like “don’t worry”

• Don’t repeatedly ask if they are alright

• Be predictable

• Help slow the person’s breathing by breathing w/ them or by counting slowly to 10

  • Hand over belly

  • Slow deep breathing

  • Remind them to keep breathing

• Do not touch them unless invited to do do

• Grounding:

  • Ice cube

  • Frozen orange

  • Feet on ground

• Anxiolytics and antidepressants used to treat panic

Anxiolytics

• Benzos

  • “pams”

• Non-benzos

Benzodiazepines

• E.g → Librium, Valium, Klonopin and Xanax

• Benzodiazepines were previously one of the most commonly used pharmacological agents for anxiety, but due to tolerance, high levels of abuse, and recent connections to dementia, they are losing favor among providers. They are now being recommended for only short-term use and should be avoided with opioid medications. Benzodiazepines promote the activity of GABA by binding to a specific receptor on the GABAA receptor complex. Fig. 4.11 shows that benzodiazepines such as diazepam (Valium), clonazepam (Klonopin), and alprazolam (Xanax) bind to GABAA receptors with different α-subunits.

  • “pams”

• MOA: Increasing the efficacy of GABA to decrease the excitability of neurons. Blocking the release of the stress hormone cortisol associated w/ panic and anxiety

  • This process reduces the communication between neurons, therefore has a calming effect on many of the functions of the brain especially the limbic system

• Side effects: (depresses CNS)

  • Drowsiness/sedation

  • Confusion

  • Ataxia

  • Dizziness

  • Respiratory depression

  • Increased irritability

  • Tolerance, dependency

  • Re-bound insomnia/anxiety

• Nursing implication:

  • Significant risk of dependence → ordered for short periods of time

  • Dangerous in overdose → especially w/ alcohol

  • Severe withdrawal symptoms if stopped abruptly → withdrawal slowly

  • Cautions + warnings →

    • Don’t operate heavy machinery or drive motor vehicle

    • Dangerous when taken w/ alcohol→ intensifies depressive effects

    • Glaucoma, dont use w/ pts w/ glaucoma unless recieving appropriate anti-glaucoma therapy

    • Don’t use pregnant or breastfeeding

    • Elderly/children → more prone to s/e and paradoxical effects (1/2 to 1/3 dose)

• Half-Life

  • Understanding the half-lives of these benzodiazepines is clinically critical for several nursing considerations:

    1. Withdrawal Risk Management

    Abrupt withdrawal after prolonged benzodiazepine use causes serious complications including:

    • Autonomic withdrawal symptoms

    • Seizures

    • Delirium

    • Rebound anxiety

    • Myoclonus (involuntary muscle contractions)

    • Sleep disturbances

    Longer half-life drugs (Valium, Librium) taper more gradually in the body, potentially causing less severe withdrawal. Shorter half-life drugs (Xanax) leave the system quickly, causing more abrupt and potentially dangerous withdrawal.

    2. Overdose and Reversal

    When benzodiazepines are combined with alcohol or other CNS depressants, outcomes can be lethal due to respiratory arrest.

    Flumazenil (benzodiazepine antagonist) reverses benzodiazepine effects, but:

    • May cause acute withdrawal syndrome, including seizures in patients on long-term therapy

    • Effectiveness and monitoring duration depend on the benzodiazepine's half-life

    A longer-acting drug may require extended monitoring even after flumazenil administration.

    3. Dosing Schedules

    Half-life determines:

    • Frequency of administration (shorter half-life = more frequent dosing)

    • Accumulation risk in the body

    • Duration of therapeutic effect

    4. Special Populations

    Older adults have:

    • Increased sensitivity to benzodiazepines

    • Decreased metabolism (Beers Criteria warns against use)

    • Higher risk of delirium, falls, and hangover effects

    Longer half-lives compound these risks through drug accumulation.

    5. Tapering Protocols

    Safe discontinuation requires gradual dose reduction—decreasing by 50% every 2 nights until reaching minimal doses. Knowing half-lives helps determine appropriate tapering schedules.

    6. Substance Use Disorder Treatment

    Benzodiazepines with cross-tolerance are used in alcohol withdrawal management. Longer-acting benzodiazepines provide smoother symptom control during detoxification.

    ---

    Clinical Bottom Line: Half-life knowledge prevents withdrawal complications, guides safe tapering, informs overdose management, and protects vulnerable populations.

Benzodiazepines Withdrawal Syndrome

• Potentially life threatening

Why are benzodiazepines addictive?

Non-bensodiazepines

Anxiety meds

• Antidepressants have been found effective in treating anxiety disorders because of many shared symptoms, neurotransmitters, and circuits. SSRIs are commonly used to treat panic disorder, generalized anxiety disorder (GAD), OCD, PTSD, and social phobia. The SNRIs venlafaxine (Effexor) and duloxetine (Cymbalta) are also used to treat GAD.

• First-Line: Antidepressants

  SSRIs (Selective Serotonin Reuptake Inhibitors) are prescribed with success for panic disorder and are the most widely prescribed for long-term treatment:

  • Fluoxetine (Prozac)

  • Sertraline (Zoloft)

  • Paroxetine (Paxil)

  • Other SSRIs

  SNRIs (Serotonin-Norepinephrine Reuptake Inhibitors) are also effective for anxiety disorders including panic.

  Important Considerations for Antidepressants:

  • Start with low doses due to activating effects that can temporarily increase anxiety

  • Treat cooccurring depression

  • Must be tapered slowly when stopping to prevent discontinuation syndrome

  • Can increase suicide risk (monitor closely)

  • In patients with bipolar disorder, may precipitate manic episodes

  Short-Term: Benzodiazepines

  Anxiolytics provide immediate relief but are indicated for short-term treatment only:

  • Alprazolam (Xanax)

  • Diazepam (Valium)

  • Lorazepam (Ativan)

  • Clonazepam (Klonopin)

  Why Short-Term Only?

  • Tolerance develops over time (requiring higher doses)

  • Addiction risk, especially with substance use history

  • Withdrawal symptoms if stopped suddenly

  • Associated with memory/cognitive concerns and dementia

  • Increased fall risk and mortality

  • Not helpful for long-term anxiety treatment

  • Paradoxical agitation possible (5% of cases, especially children/elderly)

  • Contraindicated in pregnancy and breastfeeding

  Dangerous Interactions:

  When combined with alcohol, opiates, or other CNS depressants, benzodiazepines can cause life-threatening respiratory depression.

  Combined Approach

  Psychotherapy and pharmacotherapy are frequently used together for optimal outcomes. Psychotherapy (trauma-focused CBT, exposure therapy) is typically the first-line intervention, with medications added when needed.