Chapter15/Exam2

Overview and Definitions of Anxiety

• Normal Anxiety: Viewed as a healthy and necessary life force required for survival. It provides the energy needed to carry out tasks and survive threats.

• Fear: A reaction to a specific danger, where the threat is known and identifiable.

• Anxiety: A feeling of apprehension, uneasiness, uncertainty, or dread resulting from a real or perceived threat. Unlike fear, the object of anxiety is often vague or unknown.

The Four Levels of Anxiety

• Mild Anxiety

  • Occurs in the normal experience of everyday living.

  • Allows an individual to perceive reality in sharp focus.

  • Cognitive Effects: Grasps more information effectively and provides leverage for everyday problem-solving.

• Moderate Anxiety

  • Selective Inattention: The individual sees, hears, and grasps less information than a person in a mild state.

  • Cognitive Effects: Clear thinking is hampered, and problem-solving is not optimal.

  • Physical Effects: Sympathetic nervous system symptoms begin to manifest (e.g., tension, pounding heart, increased pulse and respiration rate, perspiration, and mild somatic symptoms like gastric discomfort or headache).

• Severe Anxiety

  • Perceptual Field: Greatly reduced; the person may focus on one particular detail or many scattered details.

  • Cognition: Difficulty concentrating on the environment; thinking is fragmented.

  • Behavior: Confused and automatic behavior aimed at reducing anxiety.

  • Somatic Symptoms: Increase in severity (e.g., headache, nausea, dizziness, insomnia, trekking, and hyperventilation).

• Panic Anxiety

  • The most extreme level of anxiety, resulting in markedly disturbed behavior.

  • Behavioral Manifestations: Running, shouting, screaming, or pacing.

  • Cognition: Unable to process reality; may experience hallucinations or false sensory perceptions. Impulsivity is high.

  • Physical Effect: The person may feel they are "losing their mind" or having a heart attack.

Defense Mechanisms Against Anxiety

• Definition: Automatic coping styles that protect people from anxiety and maintain self-image by blocking feelings, conflicts, and memories.

• Adaptive Use: Lowers anxiety in a way that allows for the acceptable achievement of goals.

• Maladaptive Use: Occurs when defenses are overused, particularly immature defenses, which can interfere with reality and relationships.

Clinical Picture: Types of Anxiety Disorders

• Separation Anxiety Disorder: Characterized by developmentally inappropriate levels of concern over being away from a significant other.

• Specific Phobias: A persistent, irrational fear of a specific object, activity, or situation (e.g., heights, spiders, storm) that leads to a compelling desire for avoidance.

• Social Anxiety Disorder: Severe anxiety or fear provoked by exposure to a social or performance situation where the individual may be evaluated negatively by others.

• Panic Disorder: Characterized by panic attacks, which are abrupt surges of intense fear or discomfort reaching a peak within minutes.

• Agoraphobia: Excessive anxiety or fear about being in places or situations from which escape might be difficult or embarrassing, or where help might not be available.

• Generalized Anxiety Disorder (GAD): Characterized by excessive worry about numerous things (work, health, finances) that lasts for $6$ months or longer.

• Other Anxiety Disorders:

  • Selective Mutism: Condition where a person normally capable of speech does not speak in specific situations or to specific people.

  • Anxiety Due to a Medical Condition: Anxiety symptoms caused directly by a physiological condition (e.g., hyperthyroidism, pulmonary embolism, cardiac arrhythmias).

Risk Factors

• Genetic: Anxiety disorders often cluster in families.

• Biological: Neurobiological factors and brain chemistry (e.g., neurotransmitter imbalances).

• Psychological: Personality traits and history of trauma.

• Cultural: Ways in which anxiety is expressed and perceived within different cultural contexts.

Application of the Nursing Process for Anxiety

• Assessment

  • Perform a sound physical and neurological examination to rule out medical causes.

  • Determine if the source of anxiety is primary (the disorder itself) or secondary (caused by something else like a medical condition or substance).

  • Determine the current level of anxiety (Mild, Moderate, Severe, Panic).

  • Assess for potential self-harm or suicidal ideation.

  • Complete a full psychosocial assessment.

  • Ask the patient about identifies causes of their anxiety.

  • Self-Assessment: The nurse must assess their own feelings to avoid "catching" the patient's anxiety, which can hinder the therapeutic process.

• Nursing Diagnosis and Outcome Identification

  • Anxiety & Fear: Outcome is that the patient self-monitors intensity and uses reduction techniques.

  • Difficulty Coping: Outcome is that the patient identifies effective and ineffective patterns, asks for assistance, and modifies behavior as needed.

  • Impaired Socialization & Low Self-Esteem: Outcome is that the patient self-monitors the desire for avoidance and uses techniques to maintain role performance.

• Planning

  • Patients usually do not require inpatient admission unless they are a danger to themselves.

  • Focus on community-based interventions.

  • Encourage active participation in planning to increase positive outcomes (note: patients in severe or panic states may be unable to participate until stabilized).

• Implementation

  • Mild to Moderate: Focus on problem-solving, active listening, and providing a calm presence.

  • Severe to Panic: Provide for safety and meet physical needs (fluids, rest). Use short, simple statements. Minimize environmental stimuli.

  • Counseling: Therapeutic communication.

  • Health Teaching: Educate on the nature of the disorder and coping strategies.

  • Promotion of Self-Care: Nutrition, hygiene, and sleep.

• Evaluation

  • Does the patient experience reduced anxiety?

  • Can they recognize symptoms as anxiety-related?

  • Do they still display obsessions, compulsions, or phobias? Are they less frequent or intense?

  • Can they use new behaviors to manage anxiety?

  • Are they performing self-care and maintaining roles/relationships?

Treatment Modalities for Anxiety

• Biological (Pharmacotherapy)

  • Antidepressants: SSRIs and SNRIs are considered first-line treatments.

  • Anti-anxiety Drugs: Benzodiazepines for short-term use.

  • Other classes: Beta-blockers or antihistamines.

• Integrative Medicine: Using complementary treatments alongside traditional medicine.

• Psychological Therapies

  • Behavioral Therapy: Modeling, systematic desensitization, flooding, and thought stopping.

  • Cognitive-Behavioral Therapy (CBT): Identifying and challenging negative thought patterns.

Obsessive-Compulsive and Related Disorders

• Obsessions: Thoughts, impulses, or images that persist and recur so they cannot be dismissed from the mind.

• Compulsions: Ritualistic behaviors an individual feels driven to perform in an attempt to reduce the anxiety caused by obsessions.

• Specific Disorders:

  • Obsessive-Compulsive Disorder (OCD): Characterized by the presence of both obsessions and compulsions that interfere with daily life.

  • Body Dysmorphic Disorder (BDD): Preoccupation with an imagined or slight flaw in physical appearance, leading to false assumptions, fear of rejection, and perfectionism.

  • Hoarding Disorder: Obsessive accumulation of objects where letting go is painful; it often consumes the individual's life and alienates others.

  • Trichotillomania: Hair-pulling disorder.

  • Excoriation Disorder: Skin-picking disorder, often on the face, head, cuticles, back, limbs, hands, and feet to the point of damage.

• Risk Factors for OCD

  • Child abuse and trauma.

  • Post-infectious Autoimmune Syndrome.

  • Genetics: First-degree relatives carry $2\times$ the risk.

  • Comorbidity: Often occurs with anxiety, eating, or tic disorders.

Nursing Process for OCD

• Assessment: Focus on skin integrity (for picking/hair pulling) and self-assessment of the nurse's frustration with patient rituals.

• Nursing Diagnoses: Impaired skin integrity, disturbed body image, risk for self-destructive behavior, and chronic low self-esteem.

• Outcomes: Reduced anxiety, improved skin integrity, improved body image, and improved socialization.

• Basic Interventions:

  • Monitor for skin damage.

  • Health teaching (e.g., importance of bathroom breaks; ritualistic behavior might cause a patient to hold urine/stool).

  • Monitor for Urinary Tract Infections (UTIs) and create regular bathroom schedules.

Advanced Treatments and Therapies for OCD

• Pharmacology

  • SSRIs: FDA-approved for OCD.

  • Other Medications: Clomipramine (a TCA), Venlafaxine (an SNRI), and some antipsychotics.

  • Note: There are no specific FDA-approved drugs for Body Dysmorphic or Hoarding, though SSRIs may help with obsessive features.

• Surgical Treatments

  • Gamma Knife: Creates lesions to disconnect overactive brain circuits.

  • Deep Brain Stimulation (DBS): An implanted pulse generator uses low-dose current to reduce symptoms.

• Psychological Interventions

  • Exposure and Response Prevention (ERP): First-line CBT intervention. Exposes patient to triggers and instructs them to refrain from rituals to show that anxiety will eventually subside.

  • Flooding: Exposing the patient to a large amount of a trigger to extinguish the response.

Questions and Discussion

• Scenario (Anita): Anita is at a mall when her $5\text{-year-old}$ daughter goes missing. This would likely result in Panic-level anxiety (Page $5$). Behaviors indicating this level include running, shouting, and screaming (Page $6$).

• Scenario (Nursing Exam): The level of anxiety that could be beneficial on the day of a nursing exam is Mild Anxiety, as it improves focus and problem-solving (Page $14$).

• Scenario (Anita and Betsy): When Anita was a teenager having a panic attack at the ER, the nurse (Betsy) helped her by staying with her in a quiet spot and listening, rather than overwhelming her with talk or games (Page $24$).

• Scenario (Anton): Anton carries tissues everywhere and swipes surfaces $3$ times ($1\text{-}2\text{-}3$). This is most indicative of Obsessive-Compulsive Disorder (Page $36$). His behavior of folding and refolding for $1$ hour is done because it relieves anxiety (Page $40$).

• Scenario (Exposure and Response Prevention): Anton's therapist asks him to rest his hand on a fork or glass for an hour without using a tissue to wipe it. This is an example of Exposure and response prevention (Page $46$).

• Interventions for Panic-Level Anxiety (Discussion): When a child is missing and a parent is panicking, appropriate interventions include staying with the parent, using a calm and low-pitched voice, providing a quiet environment, and using simple, direct communication. Do not leave the person alone.