Anxiety and Anxiety Disorders

ANXIETY AS A RESPONSE TO STRESS

Stress and its Impact on the Body

  • Stress varies from person to person.
      - Common stress-inducing scenarios include public speaking, marriage, and starting a new job.

Hans Selye's General Adaptation Syndrome

  • Identified physiological aspects of stress through laboratory studies on animals.

  • Describes three stages of reaction to stress:
      1. Alarm Reaction
      2. Resistance Stage
      3. Exhaustion Stage

ALARM REACTION STAGE

  • The body's immediate response to stress involving physiological changes:
      - Messages are sent from the hypothalamus to various glands and organs.
      - The adrenal gland releases adrenaline and norepinephrine.
      - The liver reconverts glycogen stores to glucose, increasing available energy.

  • Prepares the body for defense by enhancing fuel and food supply.

RESISTANCE STAGE

  • Physiological changes include:
      - The digestive system reduces its function as blood is shunted to areas critical for defense.
      - Increased activity in lungs and heart — more air intake and accelerated heartbeat to supply oxygenated blood to vital muscles.

  • If stress is managed, the body may relax and return to normal states.

EXHAUSTION STAGE

  • Marks a negative response to prolonged anxiety and stress characterized by:
      - Depletion of body stores and reserves leading to continual arousal of physiological responses.

INTERRUPTED REACTIONS OR STAGES OF STRESS

  • Involves the autonomic nervous system, which controls involuntary activities for self-preservation:
      - Sympathetic Nerve Fibers: Charge up vital signs in response to perceived danger (e.g., adrenaline release).
      - Parasympathetic Nerve Fibers: Reverse the stress response, returning the body to normal conditions.

PHYSIOLOGICAL RESPONSE TO ANXIETY

  • Cognitive, Psychomotor, and Physiological Responses:
      - Cognitive: Difficulty with logical thought.
      - Psychomotor: Increased agitated motor activity.
      - Physiological: Elevated vital signs indicating stress.

  • Adaptive Behaviors: Techniques such as imagery, relaxation, and steady breathing to reduce discomfort.

  • Maladaptive Behaviors: Tension headaches, pain syndromes, and various stress-related responses.

LEVELS OF ANXIETY

  • Each level of anxiety elicits distinct physiological and emotional responses:
      1. Mild Anxiety: Sensation of something different, increased sensory stimulation; motivates change and goal-directed activity.
      2. Moderate Anxiety: Disturbing feelings, nervousness, agitation, and difficulty in concentrating.
      3. Severe Anxiety: Trouble with thought processes and reasoning; physical symptoms such as muscle tightening and increased vital signs.
      4. Panic Anxiety: Triggers fight, flight, or freeze responses characterized by an adrenaline surge and extreme focus on self-defensive actions.

NURSING ACTIONS BY ANXIETY LEVELS

  • Assess Anxiety Level to determine appropriate nursing actions:
      - Mild Anxiety: Can be an asset; no direct intervention needed; effective teaching is possible.
      - Moderate Anxiety: Ensure the client follows information; use short, simple sentences.
      - Severe Anxiety: Lower anxiety levels before proceeding with activities; remain in close proximity to the client, using a calm voice.
      - Panic Anxiety: Prioritize safety; move to a quiet environment, provide reassurances; nurses must remain composed and in control.

WORKING WITH CLIENTS WHO HAVE ANXIETY

STRESS-RELATED ILLNESS

  • Broad spectrum of illnesses can arise from chronic stress, including:
      - Eating disorders (e.g., anorexia nervosa, bulimia)
      - PTSD resulting from trauma
      - Somatic symptom disorders
      - Exacerbation of existing medical conditions, such as hypertension and ulcerative colitis.
      - Chronic anxiety diagnosed as anxiety disorders.

OVERVIEW OF ANXIETY DISORDERS

  • Anxiety disorders are diagnosed when anxiety becomes chronic and pervasive, leading to maladaptive behaviors and emotional disability. Common types include:
      1. Agoraphobia
      2. Panic Disorder
      3. Specific Phobia
      4. Social Anxiety Disorder (social phobia)
      5. Generalized Anxiety Disorder (GAD)

  • Panic disorder is the most prevalent, wherein episodes of severe anxiety can occur under extreme stress circumstances related to other anxiety disorders.

ASSESSMENT DATA

Key indicators include:

  • Decreased attention span

  • Restlessness and irritability

  • Poor impulse control

  • Feelings of discomfort, apprehension, or helplessness

  • Hyperactivity and pacing

  • Non-verbal signals such as wringing of hands

  • Perceptual field reductions and communication difficulties.

EXPECTED OUTCOMES

  • Immediate Outcomes:
      - Injury-free during hospitalization.
      - Ability to discuss feelings of dread and anxiety within 24-48 hours.
      - Responsive to relaxation techniques with staff aid and evidence a decrease in anxiety levels within 2-3 days.

  • Stabilization Outcomes:
      - Demonstrability in relaxation techniques without staff assistance.

  • Community Outcomes:
      - Free from anxiety attacks; effectively manages anxiety responses to stress.

IMPLEMENTATION STRATEGIES

  • Remain with the client when anxiety levels are high (severe or panic).

  • Transfer the client to a quiet area with minimal visual and auditory stimuli.

  • Administer PRN medications for heightened anxiety levels or disorganized thoughts.

  • Utilize short, clear statements; avoid forcing decisions.

  • Self-regulation of feelings and discomfort is crucial for nurses.

  • Encourage participation in relaxation exercises, aiding clients to independently manage anxiety.

  • Assist clients to reframe anxiety in a positive light as a potential catalyst for change.

  • Suggest active engagement in relationships, interests, hobbies, or activities available in the community to reduce feelings of isolation.

INCIDENCE OF ANXIETY DISORDERS

  • Anxiety disorders comprise the most prevalent psychiatric conditions within the United States, significantly affecting both adults and children. Statistics indicate:
      - Nearly 30% of individuals will experience an anxiety disorder in their lifetime.
      - Increased prevalence and substantial impact on daily functioning, particularly in women.
      - Early onset in children may lead to chronic issues if left untreated.
      - Emphasis on the importance of early detection and intervention.

PSYCHOLOGICAL AND PHYSIOLOGICAL RESPONSES TO ANXIETY

  1. Mild Anxiety:
       - Psychological: Wide perceptual field with increased sensory awareness, boosts motivation.
       - Physiological: Manifestations may include restlessness, fidgeting, or “butterflies” in the stomach.

  2. Moderate Anxiety:
       - Psychological: Diminished perceptual field resulting in selective attention.
       - Physiological: Symptoms might consist of muscle tension, pounding pulse, and headaches.

  3. Severe Anxiety:
       - Psychological: Drastic reduction in perceptual field, leading to ineffective coping behaviors.
       - Physiological: Severe headaches, nausea, trembling, etc.

  4. Panic:
       - Psychological: A focus on oneself with distorted perceptions.
       - Physiological: Symptoms such as dilated pupils, heightened blood pressure, and fight-or-flight reactions.

MEDICATIONS FOR ANXIETY DISORDERS

Types of Medications

  1. Benzodiazepines:
       - Examples: Diazepam (Valium), Alprazolam (Xanax)
       - Side Effects: Dizziness, sedation, significant potential for abuse.
       - Nursing Implications: Avoid combination with CNS depressants; clients should rise slowly from sitting positions.

  2. Non-benzodiazepines:
       - Example: Buspirone (BuSpar)
       - Side Effects: Dizziness, restlessness, nausea.
       - Nursing Implications: Administer with food; monitor for persistent restlessness.

  3. SSRIs and Other Medications:
       - Examples: Fluoxetine (Prozac), Paroxetine (Paxil), usually prescribed for panic disorder, GAD, and social phobia.
       - Nursing Implications: Vigilance for side effects and ensuring patient adherence to medication schedules.

RELATED DISORDERS: SELECTIVE MUTISM

Characteristics of Selective Mutism

  • A childhood condition where there is a failure to speak in specific social settings despite an ability to do so in other environments, such as at home.
      - Causes hindrances in social communication and educational performance due to heightened social anxiety in the affected settings.

RELATED DISORDERS: ANXIETY DUE TO ANOTHER MEDICAL CONDITION

  • Symptoms emerge directly due to a physiological health concern, which may lead to panic attacks, generalized anxiety, obsessions, or compulsions.

  • Examples of conditions causing secondary anxiety include:
      - Endocrine dysfunctions
      - Chronic obstructive pulmonary disease (COPD)
      - Congestive heart failure
      - Various neurologic conditions.

RELATED DISORDERS: SUBSTANCE/ MEDICATION- INDUCED ANXIETY DISORDER

  • Characterized by anxiety triggered directly by drug misuse, administration of medication, or toxic exposure. Symptoms can include high anxiety, panic attacks, phobias, obsessions, or compulsions. Management requires more than just medication; therapists should teach anxiety management techniques and refer clients appropriately for integrated therapy approaches.

RELATED DISORDERS: SEPARATION ANXIETY DISORDER

Overview of Separation Anxiety Disorder

  • Manifested as excessive anxiety concerning the detachment from home or significant attachment figures, typically diagnosed in children under 18 years of age.

ETIOLOGY: BIOLOGIC THEORIES / GENETICS

  • Genetics may play a crucial role in anxiety disorders, as evidenced by increased rates of anxiety seen in first-degree relatives of affected individuals.
      - Heritability refers to the extent to which genetic factors account for the disorder:
        - High heritabilities (>.6) indicate predominant genetic influences.
        - Moderate heritabilities (0.3 - 0.5) suggest a balance between genetic and environmental factors.
        - Low heritabilities (< 0.3) suggest negligible genetic roles.
      - Panic disorder, social anxiety disorder, and specific phobias demonstrate moderate heritability.
      - Generalized Anxiety Disorder (GAD) and Obsessive Compulsive Disorder (OCD) show significant familial prevalence emphasizing genetic underpinnings.

NEUROCHEMICAL THEORIES OF ANXIETY DISORDERS

  1. Gamma-aminobutyric acid (GABA):
       - Acts as an inhibitory neurotransmitter that decreases cell excitability and is critical in managing anxiety disorders by modulating signals in the limbic system.

  2. Norepinephrine:
       - Can increase cellular function; excess norepinephrine is often linked with panic disorder, GAD, and PTSD.

  3. Serotonin:
       - Affects various mood disorder dynamics and plays a defining role in GAD, OCD, and symptoms of anxiety due to its impact on aggression and emotional regulation.

PSYCHODYNAMIC THEORIES: INTRAPSYCHIC / PSYCHOANALYTIC

  • From Freud's viewpoint, anxiety is an inherent stimulus for behavior that may prompt defense mechanisms.
      - Defense Mechanisms: Cognitive distortions used unconsciously aimed at controlling awareness and reducing anxiety.
      - Overreliance on these mechanisms can hinder emotional growth and skills necessary for resolving anxiety. Ultimately, this creates challenges within interpersonal relationships.

INTERPERSONAL THEORY

  • According to Harry Stack Sullivan, anxiety arises from issues within one’s interpersonal relationships, where inadequate nurturing from caregivers can transmit anxiety to children, leading to dysfunction.

  • For adults, anxiety may be the result of pressure to comply with societal norms and values, which may hinder communication and problem-solving skills.

  • This theory culminates in Hildegard Peplau's contributions towards nursing interventions geared to develop nurturing nurse-client relationships via effective communication techniques.

BEHAVIORAL THEORY

  • This theory posits anxiety is a learned behavior that can be altered through new experiences. Maladaptive behaviors may be modified without necessitating insights into their causes through behavior modification techniques.

  • Disturbing (maladaptive) behaviors can be diminished through a process of experiences guided by therapeutic intervention.

CULTURAL CONSIDERATIONS IN ANXIETY DISORDERS

  • Societal norms affect how anxiety is expressed and perceived across different cultures. Some cultures illustrate anxiety through physical symptoms, such as headaches, while others may attribute anxiety to supernatural elements.

  • Cultural humility in nursing focuses on the importance of recognizing these variances and mitigating stereotypes when providing care.

TREATMENT FOR ANXIETY DISORDERS

  • A combination of medications and therapy typically produces better results than either strategy employed alone. Medications administered may include:
      - Antidepressants
      - Benzodiazepines
      - Cognitive–Behavioral Therapy (CBT) that focuses on positive reframing of thoughts to dispel anxiety. An example technique is to instruct clients to turn negative thoughts (e.g., "I can’t handle this") into affirmations (e.g., "This is just anxiety, and it will subside").

TREATMENT TECHNIQUES

  • Decatastrophizing: In this method, therapists address catastrophic thinking with probing questions (e.g., "What is the worst thing that could happen?"). Clients are taught techniques such as thought-stopping and distraction (e.g., splashing their face with cold water, snapping a rubber band on their wrist, or vocalizing their frustration).

  • Assertiveness Training: Clients learn to express themselves and prioritize their needs by using “I” statements to communicate both feelings and requirements.

AGE-RELATED CONSIDERATIONS IN ANXIETY DISORDERS

  • Conditions like selective mutism and separation anxiety disorder are more common in children but can persist into adulthood along with social anxiety disorder.

  • The median age of anxiety disorder onset is approximately 12 years. Conditions like phobias and social anxiety are shown to maintain consistency throughout life.

  • Anxiety in older adults is frequently linked with other disorders, such as depression or dementia, with common conditions being agoraphobia and GAD, where SSRIs are often the preferred treatment. Special caution is warranted with benzodiazepines due to the increased risk of falls and injuries in the elderly.

COMMUNITY-BASED CARE

  • Treatment is mostly sought after in community mental health and outpatient clinics, with evaluations often conducted by family practitioners or advanced nursing personnel. Nurses must possess knowledge of community resources to guide clients toward appropriate referrals for evaluations, diagnoses, and treatment options.

  • Referral resources could include psychiatrists or psychiatric nurse practitioners, along with support from community self-help or anxiety groups that aim to alleviate feelings of isolation.

MENTAL HEALTH PROMOTION

  • Recognizing anxiety as a warning sign for ineffective stress management can provide an opportunity for the necessary changes. Notably, positive life events (e.g., employment, marriage, children) can also induce anxiety. Managing stress and anxiety is vital for maintaining holistic health and well-being.

TIPS FOR MANAGING STRESS

  • Accept unchangeable events.

  • Communicate assertively.

  • Express your feelings openly.

  • Use humor (laughter, crying) as an emotional outlet.

  • Learn relaxation techniques including guided imagery and meditation.

  • Maintain regular exercise and a balanced diet.

  • Limit caffeine and alcohol consumption.

  • Prioritize adequate rest and sleep.

  • Set realistic goals that match your lifestyle.

  • Identify and engage in meaningful activities.

PANIC DISORDER

Definition and Symptoms

  • Panic disorder is characterized by discrete episodes of panic attacks lasting between 15 to 30 minutes, accompanied by rapidly escalating anxiety. Symptoms can manifest as follows:
      - Palpitations, sweating, and tremors.
      - Shortness of breath and chest pain.
      - Nauesua, dizziness, and temperature variations (chills or hot flashes).

Diagnosis Criteria for Panic Disorder

  • Must include:
      - Recurrent, unintended panic attacks.
      - Persistent concern over future attacks for a minimum of one month.
      - Observable significant behavioral changes stemming from attacks.

Panic Attacks & Risk Factors

  • First episodes typically occur without an identifiable environmental trigger, leading to increased suicidality risks, especially in younger, unmarried females with lower educational status. Prior trauma is pivotal and must be addressed. Approximately half of those diagnosed with panic disorder also experience accompanying agoraphobia.

Clinical Course of Panic Disorder

  • The peak onset arises in late adolescence to mid-30s, and panic symptoms can emerge even without visible threats. Fear arising from memories of past attacks may drive avoidance behaviors, especially concerning public locations. This can result in:
      - Agoraphobia: The fear of being outdoors or in public settings.
      - Primary Gain: Securing relief from anxiety by steering clear of anxiety-provoking circumstances.
      - Secondary Gain: Deriving attention and care from others, which further fosters avoidance behavior.

TREATMENT OF PANIC DISORDER

  • A multifaceted approach is essential, incorporating:
      - Cognitive-Behavioral Therapy (CBT): Encompasses deep breathing and relaxation exercises.
      - Medications: These can include benzodiazepines, SSRIs, tricyclic antidepressants, and antihypertensives such as clonidine and propranolol.

CLIENT ASSESSMENT FOR PANIC DISORDER

Assessment Data Includes:

  • Hamilton Rating Scale for anxiety to provide a quantitative measure.

  • Detailed client history concerning panic attacks.

  • Observation of general appearance and motor behavior.

  • Assessment of mood and emotional affectivity.

  • Analysis of thought processes, sensorium, and cognitive insights.

  • Attention to self-concept, interpersonal roles, and physiological upkeep.

Common Problems for Clients with Panic Disorder:

  • Risk of injury, heightened anxiety, low situational self-esteem, ineffective coping strategies, feelings of powerlessness, ineffective role performance, and disrupted sleep patterns.

DATA ANALYSIS AND PRIORITIES

  • Prioritize accurately identifying the anxiety levels to direct proper interventions, ensuring the client is safe and supported during experiences of panic or high anxiety.

OUTCOME IDENTIFICATION

Desired Outcomes for Clients with Panic Disorder Include:

  • Remain injury-free.

  • Communicate feelings and concerns clearly.

  • Exhibit effective coping mechanisms.

  • Manage anxiety responses successfully.

  • Express personal control over their circumstances.

  • Maintain nutritional intake with adequate amounts of sleep, targeting 6 hours or more per night.

PROMOTING SAFETY AND COMFORT

  • Ensure a safe, private environment during panic attacks, transferring clients to quieter spaces when necessary.

  • Stay with the client and maintain calm, soothing communication while giving succinct directional cues to ease their panic.

USING THERAPEUTIC COMMUNICATION

  • Foster collaboration with clients in both assessment and treatment planning frameworks. Communicate using straightforward, calming language, and consider physical engagement, such as walking alongside clients when verbal communication becomes difficult due to heightened anxiety. Employ open-ended questions as clients appear calmer.

ACTIONS AND RATIONALE FOR MANAGING HIGH ANXIETY

  • Remain with the client at all times under severe or panic-induced anxieties to assure safety and prevent escalation. Shift the client to settings with less stimuli to reduce potential anxiety triggers.

  • Administering PRN medications can help to lower anxiety levels efficiently.

  • Maintain a calm demeanor to instill a sense of security in clients.

  • Use clear and simple expressions to foster comprehension and prompt responses from anxious clients.

ENCOURAGING RELAXATION AND POSITIVE ACTIVITIES

  • Promote engagement in relaxation exercises, such as:
      - Deep breathing
      - Progressive muscle relaxation
      - Meditation

  • Emphasize that these methods offer non-chemical methods for anxiety reduction which cultivate confidence.

  • Educate clients on utilizing relaxation strategies independently to furnish them with an enhanced sense of control over their anxiety.

  • Frame mild anxiety in a positive light, promoting it as an impetus for beneficial change rather than a hindrance.

ADDITIONAL ACTIONS FOR MANAGING ANXIETY

  • Avoid compelling clients to make choices during periods of high anxiety, as decision-making might be challenging.

  • Nurses should remain self-aware regarding their emotional responses since anxiety is often communicable.

  • Encourage social engagement, personal interests, hobbies, or recreational activities to mitigate focus on anxiety itself.

PHOBIAS

Definition of Phobia

  • Defined as an illogical, intense, and persistent fear of a specific object or social situation, causing significant distress and disrupting normal functioning. Phobias present with characteristics such as:
      - Responses that may be exaggerated in relation to the perceived threat.
      - Recognition of irrational fear without the ability to control it.
      - Phobic disorders carry potential heritable traits.
      - Anticipatory anxiety can also arise before impending encounters with phobic stimuli, resulting in avoidance behaviors.

Categories of Phobias Include:

  1. Agoraphobia

  2. Specific Phobia

  3. Social Anxiety or Phobia

TYPES OF SPECIFIC PHOBIAS

  • Defined as an irrational fear of designated objects or situations diagnosed only if said fears disrupt life profoundly. Categories encompass:
      - Natural environmental phobias (e.g., storms, heights)
      - Blood-injection phobias (e.g., fear related to seeing blood or medical interventions)
      - Situational phobias (e.g., fear of elevators or bridges)
      - Animal phobias prevailing from childhood experiences.

ONSET AND CLINICAL COURSE OF PHOBIAS

  • Specific phobias typically manifest during childhood or adolescence and often continue into adulthood (present in 80% of cases). Social phobias peak in middle adolescence, showing a continuous pattern that may attenuate with age, although severity is responsive to life stressors.

TREATMENT OF PHOBIAS

  • Behavioral therapy, emphasizing education about anxiety and its responses, is key to treatment. Techniques employed include relaxation, goal development, and visualization strategies.

  • Systematic Desensitization: gradual exposure to phobic objects in a secure environment to incrementally increase familiarity and comfort.

  • Flooding: a rapid desensitization technique where clients confront phobic objects continuously till their anxiety subsides, executed by trained therapists.

  • Medications: Various options exist for phobia treatment, which should refer to comprehensive lists for specific details.

GENERALIZED ANXIETY DISORDER (GAD)

Definition and Symptoms

  • Identified by excessive worrying and anxiety that occurs for at least 50% of the time over 6 months. Individuals may experience symptoms including uneasiness, irritability, fatigue, muscle tension, cognitive difficulties, and alterations in sleep patterns.

  • More prevalent among older adults and significantly impacts quality of life.

Treatment Options

  • Common pharmacological approaches include Buspirone (BuSpar) and SSRIs or serotonin-norepinephrine reuptake inhibitors for effective symptom management.

MANAGING ANXIETY

  • Educate clients on various relaxation techniques:
      - Deep Breathing
      - Guided Imagery
      - Progressive Relaxation

  • Introduce cognitive restructuring techniques in calm states to ensure applicability during panic attacks for regaining control over anxiety.

  • Effectively managing panic attacks facilitates a reduction in overall anxiety levels.

PROVIDING CLIENT AND FAMILY EDUCATION

  • Instill knowledge on stress management and coping with anxiety triggers, promoting a combined psychotherapy and medication approach.

  • Explain the physiology behind anxiety disorders, overviewing medication regimens along with potential effects and side effects.

  • Encourage regular physical activity to diminish panic responses while enhancing overall well-being.

EVALUATION

  • Individual assessments of care plans should occur frequently to ascertain whether treatment outcomes are achieved. Assessing the client's perspective on treatment success is critical, as is ensuring that their comfort and quality of life align with treatment goals.

SOCIAL PHOBIA (SOCIAL ANXIETY DISORDER)

Definition and Symptoms

  • Social phobia entails severe anxiety in social or performance-related contexts, leading to fears of judgment and embarrassment. Common triggers may involve scenarios such as:
      - Making public speeches.
      - Attending social gatherings solo.
      - Interacting with strangers or the opposite sex.
      - Engaging in certain private acts like eating or using restrooms in public.
      - Experiencing an overwhelming fear of becoming the focal point of attention.