Anxiety Disorders and Treatment

Anxiety

Marjorie Shragher MSN RN PCCN

Facts

  • Anxiety is one of the most common psychiatric disorders in the U.S.
  • It affects 40 million adults age 18 and older, which is 18.1%18.1\% of the U.S. population.
  • Anxiety is more common among women than men.
  • Anxiety costs the U.S. more than 4242 billion a year, almost one-third of the country's 148148 billion total mental health bill.

Facts

  • More than 22.8422.84 billion of the costs associated with anxiety are related to the repeated use of healthcare services, as those with anxiety disorders seek relief for symptoms that mimic physical illnesses.
  • People with an anxiety disorder are 3 - 5 times more likely to go to the doctor and 6 times more likely to be hospitalized for psychiatric disorders than non-sufferers.

Learning Outcomes

  • Describe various types of anxiety and anxiety-related disorders and identify symptomatology associated with each
  • Formulate client problems and outcome criteria for patients with anxiety disorders
  • Describe appropriate nursing interventions/actions for behaviors associated with anxiety disorders
  • Discuss various modalities relevant to the treatment of anxiety disorders
  • Evaluate the effectiveness of treatment for a client diagnosed with anxiety disorder

Anxiety, Stress, Fear

  • Often used interchangeably.
  • Stress or stressor is the external pressure on the individual.
  • Anxiety is the emotional response to that stressor.
  • Fear is the intellectual appraisal of a threatening stimulus.

Panic Disorders

  • Recurrent unexpected panic attacks include:
    • Intense apprehension, fear, or terror.
    • Feelings of impending doom.
    • Intense physical discomfort.

Panic Symptoms

  • Palpitations, pounding heart, or accelerated heart rate.
  • Sweating.
  • Trembling or shaking.
  • Sensations of shortness of breath (SOB) or smothering.
  • Feeling of choking.
  • Chest pain or discomfort.
  • Nausea or abdominal distress.
  • Feeling dizzy, unsteady, lightheaded, or faint.
  • Derealization or depersonalization.
  • Fear of losing control or going crazy.
  • Fear of dying.
  • Paresthesia (numbness or tingling).
  • Chills or hot flashes.

Generalized Anxiety Disorder

  • Chronic, unrealistic & excessive anxiety & worry for at least 6 months.
  • Symptoms affect social and occupational areas of functioning.
  • Symptoms include:
    • Excessive worry.
    • Restlessness/on edge.
    • Fatigue.
    • Difficulty concentrating/mind “going blank”.
    • Irritability.
    • Muscle tension.
    • Sleep disturbance.

Phobias

  • Persistent, irrational fear of something specific.
  • Magnified, distorted perception that doesn’t “fit” with the actual degree of danger.

Phobia Types

  • Agoraphobia:
    • Fear of being in places or situations from which escape might be difficult.
  • Social Phobia:
    • Excessive fear of doing something embarrassing.
    • Being evaluated negatively by others.
  • Specific phobias:
    • High levels of anxiety/fear provoked by specific objects or situations (dogs, storms, etc.).

Anxiety Disorder Due to Another Medical Condition and Substance/Medicine-Induced Anxiety Disorder

  • Related to a medical disorder such as:
    • Cardiac issues: MI, CHF, MVP
    • Endocrine: hypoglycemia, hypo/hyperthyroidism
    • Respiratory: COPD, hyperventilation
    • Neurological: complex partial seizures
    • It is important to look at the underlying cause.
  • Medication-induced anxiety is related to substances:
    • Intoxication or withdrawal.

Anxiety Disorders

  • Separation Anxiety:
    • Fear of separation from an individual.

Obsessive-Compulsive Disorder (OCD)

  • Obsessions:
    • Thoughts, impulses, or images that persist & recur and cannot be dismissed from the mind.
    • Seem senseless but still create severe anxiety.
    • Individuals recognize that the thoughts are a product of their own mind.
  • Compulsions:
    • Ritualistic behaviors.
    • Individuals feel driven to perform compulsions in an attempt to prevent or reduce anxiety.
    • Compulsive acts temporarily relieve anxiety.
    • Rituals are time-consuming and interfere with normal routines, relationships, & work.

OCD and Related Disorders

  • Body Dysmorphic Disorder:
    • Preoccupation with a perceived flaw.
    • Repetitive behaviors (mirrors, skin picking).
    • Social impairment that does not fit other condition criteria.
  • Trichotillomania:
    • Hair pulling out.
    • Sense of relief.
    • Can begin in childhood.
  • Hoarding:
    • Cannot part with possessions.
    • Functional impairments and stress occur.

Trauma-Related Disorders

  • Symptoms following exposure to an extreme traumatic stressor/experience involving personal threat:
    • Experienced or witnessed.
  • Acute Stress Disorder:
    • 33 days to one month.
  • Post-Traumatic Stress Disorder (PTSD):
    • Longer than one month.
  • Characteristic symptoms include:
    • Re-experiencing the traumatic event through flashbacks.
    • Sustained high level of anxiety or arousal.
    • General numbing of responsiveness.
    • Intrusive recollections or nightmares of the event.
    • Depression symptoms.

Trauma/Stress Disorders

  • Adjustment Disorder:
    • Less severe than PTSD.
    • Characterized by depression, anxiety, erratic behaviors.
    • Lasts 3−63-6 months.

Dissociative Disorders

  • Dissociative Amnesia:
    • Inability to recall important personal information after a stressful event.
  • Dissociative Fugue:
    • Sudden travel away from home or workplace and the individual cannot recall things or self.
  • Depersonalization-Derealization Disorder:
    • Depersonalization is defined as a disturbance in the perception of oneself.
    • Derealization is described as an alteration in the perception of the external environment.
  • Dissociative Identity Disorder:
    • Formerly Multiple Personality Disorder.

Dissociative Identity Disorder

  • Two or more personalities in a single individual.
  • One is evident at any given time.
  • One is usually dominant.
  • Transition is sudden, often dramatic, usually precipitated by stress.
  • Original personality usually has no knowledge of others.
  • Subpersonalities are often aware of each other.

Somatoform Disorders

  • Somatization:
    • Expression of psychological stress through physical symptoms.
    • Somatoform disorders are a group of conditions in which somatization is present.
  • Somatic Symptom Disorder:
    • One or more symptoms that are distressing and disrupt life.
  • Illness Anxiety Disorder:
    • A preoccupation with fear of contracting, or the belief of having, a serious disease.
    • "Doctor shopping" may occur.

Somatoform Disorders

  • Conversion Disorder (Functional Neurological Symptom Disorder):
    • Loss of bodily function without a detectable pathophysiology.
    • Individuals are unaware of the psychological basis & are unable to control symptoms.
    • Examples include Aphonia (loss of voice), Pseudocyesis (false pregnancy), Anosmia (inability to perceive smell).
    • La belle indifference (lack of concern about the symptoms).

Somatoform Disorders

  • Factitious Disorder Imposed on Self:
    • The individual pretends to be sick and presents the illness to others.
    • There are no external rewards.
  • Factitious Disorder Imposed on Another:

Psychodynamic Theory (Freud)

  • GAD: Overuse or ineffective use of ego defense mechanisms results in maladaptive responses to anxiety.
  • Phobia: Related to unconscious fears.
  • OCD: Channels thoughts and behaviors to prevent aggression.
  • Dissociative Disorders: Repress memories to protect from emotional pain.
  • Somatic Disorders:
    • Physical complaints are an expression of low self-esteem.
    • It's easier to feel something is wrong with the body instead of self.

Theories: Freud

  • Illness anxiety disorder and Somatic symptom disorder:
    • Views self as bad and deserving of punishment.
    • It's easier to have something physically wrong.
  • Conversion disorder:
    • Emotions associated with a traumatic event that are deemed unacceptable to express.
    • Possibly related to abuse.

Theories: Biological Aspects

  • Genetics
  • Neuroanatomical
  • Biochemical
  • Neurochemical
  • Medical Conditions

Theories

  • Learning Theory
  • Cognitive Theory
    • Faulty, distorted, or counterproductive thinking.
    • Maladaptive behaviors and emotional disorders.
  • Temperament
    • Born that way

Etiological Implications: PTSD

  • Psychosocial Theory
    • The traumatic experience:
      • Severity, preparedness, death exposure, numbers affected, any preparation, location.
    • The individual:
      • Ego strength, coping resources, preexisting condition, previous experiences, developmental stage, demographics.
    • The recovery environment:
      • Social support, family and friends, societal attitudes, cultural influences.

Etiological Implications: PTSD

  • Biological Aspects
    • Suggests that a person who has experienced previous trauma:
      • Is more likely to develop symptoms after a stressful life event.
      • May be more likely to become exposed to future traumas.
      • Reactivates those behaviors associated with the original trauma.
  • Learning Theory
    • Negative reinforcement as behavior that leads to a reduction in an aversive experience, thereby reinforcing and resulting in repetition of the behavior.
    • Avoidance behaviors.
    • Psychic numbing.

Etiological Implications: PTSD

  • Cognitive Theory
    • An individual is vulnerable to PTSD when:
      • Fundamental beliefs are invalidated.
      • A sense of helplessness and hopelessness prevail.

Somatoform Disorders: Etiological Implications

  • Family Dynamics
    • When a child is ill, a family that has difficulty expressing emotions shifts from conflict to the child’s illness.
    • Underlying issues are not confronted openly.
    • Brings some stability to the family (harmony replaces discord) & the child receives positive reinforcement for illness.
    • Focus from family to child is a tertiary gain.

Somatoform Disorders: Etiological Implications

  • Learning Theory
    • Somatic complaints are reinforced when a sick person replaces stressful obligations or situations with illness (primary gain).
    • Person becomes the focus of attention because of illness (secondary gain).
    • Relieves conflict within the family as concern is shifted to the ill person and away from the real issue (tertiary gain).

Assessment: Recognizing Cues

  • Anxiety
  • Phobias​
  • Women​
  • Medical Conditions​
  • Adverse Reaction to a Medication or Substance​
  • Trauma and Stress​
  • Experience, witness, or re-experience a traumatic event​
  • Somatic Disorders​
  • Women​
  • Genetic​
  • Learned​
  • Trauma​
  • Depression, Anxiety, personality disorder

Assessment: Screening

  • Assessment is related to the Disorder​
  • Risk of suicide / aggression​
  • History / symptoms​
  • Rule out medical causes for anxiety​
  • Determine the level of anxiety​

Assessment Screening

  • Use of assessment scales​
    • HAM-A (Hamilton Anxiety Rating Scale)
    • Self: Beck Anxiety Inventory; Zung Self-Rated Anxiety Scale​
    • Panic Disorder Severity Scale​
    • Fear questionnaire​
    • Yale-Brown Obsessive Compulsive Scale​
    • Patient Health Questionnaire-15 (PHQ-15)

Client Problems

  • Anxiety
  • Impaired memory
  • Powerlessness
  • Risk for suicide
  • Ineffective Coping
  • Fear
  • Disturbed body Image
  • Poor impulse control
  • Post-Trauma Syndrome

Client Problems

  • Complicated or Maladaptive grieving
  • Risk-prone behavior
  • Disturbed Personal Identity
  • Disturbed Sensory Perception

Nursing Implementation

  • Interventions are aimed at:
    • Anxiety at a manageable level
    • Problem-solving to increase patient’s level of personal control
    • OCD: associate ritual with anxiety
    • Phobia: function in the presence of feared stimulus.
    • Somatoform:
      • Accurate Assessment
      • Relief of discomfort
      • Coping with stress by means other than preoccupation with physical symptoms

Nursing

  • Restoring normal thought processes
  • Coping strategies to deal with stress other than dissociation from the environment
  • Dissociative Identity disorder
    • Goal:
      • Integration: all the personalities into one
      • Mentally re-experience abuse (abreaction)
      • Therapy explores each person

Nursing Interventions/Action/Implementation

  • Self-Assessment
  • Environment
  • Other conditions
  • Depression and/or suicidal ideation
  • During Panic Attack
    • Safety
    • Stay with the patient
    • Remain Calm
    • Use Direct/concise communication
    • Decrease Stimuli

Nursing

  • Therapeutic relationship
    • Accepting attitude
    • Encourage Talking
    • Acknowledge & validate feelings
    • Provide Positive feedback
    • Encourage independence
    • Educate the patient

Nursing: Taking Action/Implementation

  • Identify triggers
  • Identify coping mechanisms
  • Teach anxiety-reducing strategies
  • Assist with decisions but limit choices
  • Promote Exercise
  • Assist with Activities of Daily Living (ADLs)
  • Schedule self-care activities

Nursing: Taking Action/Implementation

  • Rituals:
    • Taper off gradually
  • Administer Medication as prescribed
  • Use Grounding techniques if a patient dissociates (focus on the here and now)
  • Accept somatic symptoms
  • Report new medical complaints
  • Assess the gain for the symptom
  • Allow for somatic symptom discussion, but limit the time spent

Taking Action/Implementation

  • Educate on the disorder:
    • Manifestations, treatments, medication, support
    • Timing is key
  • Encourage Exercise
  • Recognize escalating anxiety
  • Plan for the future
  • Refer for further treatment

Therapy

  • Psychotherapy
  • Cognitive Therapy
  • Behavior Therapy
  • Family Therapy
  • Regular physical exercises
  • Cognitive behavior therapy

Therapy

  • Behavior Therapy
    • Systematic Desensitization
    • Implosion Therapy (flooding)
    • Relaxation Training
    • Modeling
    • Thought stopping
    • Response prevention

Therapies

  • Cognitive Behavior therapy
  • Prolonged exposure therapy
  • Group/family therapy
  • Eye movement desensitization and reprocessing (EMDR)
  • Trauma-informed care
  • Digital therapeutics

Collaborative Care: Dissociative Disorders

  • Collaborative Care
    • Individual psychotherapy
    • Hypnosis
    • Supportive care
    • Integration therapy (DID)
      • Goal to blend all personalities into one

Treatment Dissociative amnesia

  • Many times, when the stressor is removed, amnesia resolves
  • Amobarbital Sodium
    • Sedative/hypnotic
  • Hypnosis
  • Psychotherapy
  • Cognitive behavior therapy

Treatment

Depersonalization-Derealization disorder

  • Combo antidepressants, mood stabilizers, anticonvulsants, and antipsychotics
  • Hypnotherapy
  • Cognitive behavior therapy

Pharmacological

  • General Classifications of Drugs Used to Treat Anxiety
    • Benzodiazepines
    • Non-benzodiazepines & miscellaneous agents
    • Antidepressants
    • Antihypertensive
    • Ketamine
    • Cannabinoids
    • Anticonvulsants

Pharmacological

  • Drugs of Choice: Benzodiazepines
    • Generalized Anxiety Disorder (GAD)
    • Short-term insomnia therapy (approx. 4 weeks)
    • GAD, pre-op anxiety, ventilator anxiety
    • Off-label uses: Seizures, alcohol withdrawal, status epilepticus
    • Metabolized in the liver, excreted in the kidneys
    • Tolerance develops
    • Potential for dependence
    • OD with alcohol may be fatal

Pharmacological

  • Commonly used for anxiety:
    • alprazolam (Xanax)
    • chlordiazepoxide (Librium)
    • clonazepam (Klonopin)
    • clorazepate (Tranxene)
    • diazepam (Valium)
    • lorazepam (Ativan)
    • oxazepam (Serax)

Pharmacological

  • GABA receptor agonist
    • Facilitates transmission of GABA (gamma-aminobutyric acid)
  • Contraindications
    • Pregnancy, Lactating Women, Narrow Angle Glaucoma, Psychosis, COPD
  • Precautions
    • Hepatic and Renal Dysfunction
    • Children
    • Grapefruit inhibits the metabolism of Xanax
    • Valium is used for benzodiazepine withdrawal

Pharmacological

  • Common Adverse Effects
    • Dizziness
    • Ataxia
    • Drowsiness
    • Blurred vision
    • Vertigo
    • Sedation
    • Confusion
  • Less Common
    • Hepatotoxicity, alopecia, anaphylaxis
    • Cardiac changes after rapid IV
    • Paradoxical CNS stimulation
    • Psych patients, elderly, and ADHD

Pharmacological Nursing: Recognizing Cues

  • Assess for paradoxical CNS excitement
  • Assess for history of smoking
  • Assess vital signs, CBC, liver function
  • Assess needs for antianxiety drugs
  • Assess for signs/symptoms of overdose or abuse
  • Teach nonpharmacologic methods of sleep and relaxation
  • Acute phase, taper off
  • OD signs/symptoms: sedation, lethargy, coma
  • Reversal agent: flumazenil (Romazicon)
  • & gastric lavage and activated charcoal

Pharmacological Antihypertensive Agents

  • Beta Blockers:
    • Propranolol, Atenolol, metoprolol
  • Alpha2-receptor agonists
    • Clonidine
  • PTSD
  • Alpha Blocker: Prazosin
    • Reduce autonomic nervous system symptoms (nervousness, tremor, tachycardia)

Psychopharmacology: Miscellaneous

  • buspirone (Buspar)
    • Nonbenzodiazepine anxiolytic
    • Mechanism of action unclear – appears to enhance dopamine receptors and suppress serotonin receptors
    • Used for GAD
    • Common side effects: dizziness, drowsiness, nausea, vomiting, headache
    • Takes 10-14 days to achieve optimal results

Psychopharmacology: Antidepressants

  • Frequently used to treat anxiety
  • Alter norepinephrine and serotonin
  • Serotonin Reuptake Inhibitors (SSRIs)
  • Serotonin-norepinephrine Reuptake Inhibitors (SNRIs)
  • Tricyclic Antidepressants (TCAs)
  • Monoamine Oxidase Inhibitors (MAOIs)

Psychopharmacology: Antidepressants

  • SSRIs
    • Mechanism of action: inhibit reuptake of serotonin
    • Safer Use
    • Fewer sympathomimetic effects
      • Increased HR, HTN, etc.
    • Fewer anticholinergic affects
      • Dry mouth, urinary hesitancy, etc.
    • May cause weight gain, sexual dysfunction

Psychopharmacology: Antidepressants

  • SSRIs (continued)
    • GAD
      • Paroxetine (Paxil), escitalopram (Lexapro)
    • Panic Disorder/PTSD/Social anxiety Disorder
      • Paroxetine (Paxil), sertraline (Zoloft)
    • OCD
      • Paroxetine (Paxil), fluvoxamine (Luvox) fluoxetine (Prozac), sertraline (Zoloft)

Psychopharmacology: Antidepressants

Serotonin-norepinephrine Reuptake Inhibitors (SNRIs)

  • Duloxetine (Cymbalta)
  • (Venlafaxine) Effexor

Psychopharmacology: Antidepressants

  • Tricyclic Antidepressants (TCAs)
    • Clomipramine (Anafranil)
    • Doxepin (Sinequan)
  • Contraindications
    • Hx MI, heart block, dysrhythmias
    • Asthma, GI disorders, alcoholism, schizoid, bipolar
    • Avoid use with alcohol
  • Adverse effects
    • Anticholinergic affects

Psychopharmacology: Antidepressants

  • Monoamine Oxidase Inhibitors (MAOIs) – Rare use – High incidence adverse effects
    • Avoid foods containing tyramine
    • Avoid tyrosine
    • Avoid caffeine
    • Potentiates the effect of insulin and diabetic drugs
    • Commonly causes hypotension, HA, and diarrhea

Psychopharmacology

  • Barbiturates: Phenobarbital, Secobarbital, Pentobarbital
    • Powerful CNS depressant,
    • Sedative/hypnotic
    • Binds to GABA receptors where it enhances the activity of GABA
    • Coma, Steven-Johnson’s Syndrome, angioedema, thrombophlebitis
    • Hangover, depression over sedation hallucinations
    • Blood dyscrasias, hypocalcemia,
    • Paradoxical excitement

Psychopharmacology

  • Barbiturates OD
    • Severe respiratory depression
      • ? Think about the airway
    • Severe and fatal
    • Medical emergency
    • Treatment: activated charcoal with gastric lavage
    • Sodium bicarbonate increases renal elimination

Psychopharmacology Ketamine

  • General anesthetic
  • Blocks afferent impulses of pain
  • Suppresses spinal cord activity
  • Affects the CNS transmitter system
  • Can produce dissociative state
  • Side effects: ICP, HTN, hypotension, respiratory depression, Tachy/Brady, LOC
  • Assess: LOC, BP, ECG, respiratory status, ECG

Evaluation

Effectiveness of Interventions

  • Medications effectiveness

References

  • ATI. (2023). Content Mastery Series Review Module: RN Pharmacology for Nursing (9th ed.). Assessment Technology Institute.
  • ATI . (2023). RN Mental Health Nursing: Content Mastery Series Review Module (12th ed.). Assessment Technologies Institute .
  • Townsend, M. C. (2023). Essentials of Psychiatric Mental Health Nursing, Concepts of Care in Evidence Based Practice (9th ed.). Philadelphia, PA: F.A. Davis.