Anxiety

ANXIETY INTRODUCTION

  • Definition of Anxiety:

    • An anxiety is a universal human experience, categorized as one of the most fundamental emotions.

    • It encompasses feelings of apprehension, uncertainty, or dread, resulting from a real or perceived threat.

  • Normal Anxiety:

    • Considered a healthy reaction; it serves as an essential evolutionary strategy for survival.

ANXIETY PATHOPHYSIOLOGY

  • Key Mediators in Central Nervous System:

    • Norepinephrine

    • Serotonin

    • Dopamine

    • Gamma-Aminobutyric Acid (GABA)

  • Role of the Autonomic Nervous System:

    • Mediates most symptoms of anxiety; particularly the sympathetic nervous system.

  • Causes of Anxiety Disorders:

    • Caused by the interaction of several factors, including genetic vulnerability.

    • Factors interact with situations, stress, or trauma, leading to clinically significant syndromes.

ANXIETY PATHOPHYSIOLOGY - Rule Out Medical Causes

  • Necessary Steps for Diagnosis:

    • Table 15.7 (see Psych Workbook for details).

    • Rule out other causes that may include:

    • Caffeine-containing beverages

    • Over-the-counter (OTC) medicines

    • Herbal medications

    • Street drugs

  • Basic Laboratory Studies:

    • Complete blood cell count

    • Chemistry profile

    • Thyroid function tests

    • Urinalysis

    • Urine drug screening

ANXIETY LEVELS OF ANXIETY

  • Peplau’s Levels of Anxiety:

    • Mild

    • Moderate

    • Severe

    • Panic

ANXIETY LEVELS OF ANXIETY - Mild Anxiety

  • Characteristics:

    • Normal occurrence in daily life; allows clear perception of reality.

    • Enhances information processing and problem solving.

  • Physical Symptoms:

    • Slight discomfort, restlessness, or minor tension-relieving behaviors, e.g., nail biting, foot or finger tapping, fidgeting.

ANXIETY LEVELS OF ANXIETY - Moderate Anxiety

  • Characteristics:

    • Perceptual field narrows; details are often excluded from attention.

    • Exhibits selective inattention where only certain environmental aspects are focused on.

  • Cognitive Function:

    • Clear thinking is hampered; suboptimal learning and problem solving can occur.

  • Physical Symptoms:

    • Activation of sympathetic nervous system, increased pulse, increased respiratory rates, perspiration, gastric discomfort, headache, and urinary urgency.

ANXIETY LEVELS OF ANXIETY - Severe Anxiety

  • Characteristics:

    • Greatly reduced perceptual field, focusing on one specific detail or scattered details.

    • Excludes most external stimuli; learning and problem solving become impossible.

  • Physical Symptoms:

    • Pounding heart, trembling, hyperventilation, feelings of impending doom, headache, nausea, and dizziness.

ANXIETY LEVELS OF ANXIETY - Panic Anxiety

  • Characteristics:

    • Most extreme anxiety level leading to highly dysregulated behavior and loss of reality.

    • Could involve pacing, running, screaming, or total withdrawal.

  • Physical Symptoms:

    • Include racing heart, sweating, chills, hot flashes, trembling, shortness of breath, weakness, dizziness, tingling or numbness in hands, headache, nausea, abdominal cramping, chest pain.

DEFENSE MECHANISMS

  • Definition:

    • Psychological strategies employed unconsciously to protect individuals from anxiety generated by unacceptable thoughts or feelings.

ANXIETY RISK FACTORS

  • General Risk Factors:

    • White race

    • Female gender

    • Family history of anxiety or Major Depressive Disorder (MDD)

    • Disturbed family environment

    • Early parental loss

    • Childhood sexual abuse

    • Substance use disorder

    • Traumatic events

    • Lower educational attainment

    • Low self-esteem

ANXIETY RISK FACTORS - Specific Types

  • Vary by Anxiety Disorder Type:

    • Shyness or distress in new situations during childhood

    • Exposure to stress or negative life events

    • Family history of anxiety or mental disorders.

ANXIETY SIGNS & SYMPTOMS

  • Physical and Psychological Symptoms:

    • Restlessness, feeling wound-up or on-edge

    • Easily fatigued

    • Difficulty concentrating

    • Irritability

    • Somatic complaints such as headaches, muscle aches, stomach aches

    • Difficulty controlling worry

    • Sleep problems, including difficulty with sleep onset or maintenance.

ANXIETY DESIRED OUTCOMES

  • Objective Goals:

    • Experience decreased anxiety

    • Demonstrate effective coping with anxiety

    • Show improved knowledge of treatment plans.

ANXIETY INTERVENTION GUIDELINES

  • Treatment Approaches:

    • Counseling, milieu therapy, promotion of self-care activities

    • Pharmacological and biological interventions

    • Health education interventions.

  • Techniques:

    • Relaxation methods like progressive relaxation.

    • Identification of community resources for specialized treatment.

    • Support groups for patients and families specific to anxiety disorders.

ANXIETY GENERAL INTERVENTIONS TO DECREASE ANXIETY

  • Strategies:

    • Foster a calm environment by reducing stimuli.

    • Provide reassurance of support.

    • Assist in calming anxiety from severe or panic to mild with slow deep breathing or prescribed medication.

    • Encourage discussion about feelings and concerns.

    • Reframe problems into solvable formats.

    • Identifying triggers of anxiety prior to onset.

ANXIETY GENERAL INTERVENTIONS TO DECREASE ANXIETY - Techniques

  • Teaching Methods:

    • Teach relaxation techniques such as deep breathing, meditation, or progressive muscle relaxation.

    • Identify and address negative self-talk.

    • Refer patients and significant others to support groups and self-help programs.

ANXIETY GENERAL INTERVENTIONS TO IMPROVE COPING

  • Recommendations:

    • Monitor positive coping skills and encourage new alternatives to ineffective ones.

    • Explain the fight-or-flight response and how controlled breathing can invoke a relaxation response.

    • Teach visualization and other relaxation techniques.

ANXIETY GENERAL INTERVENTIONS TO IMPROVE COPING - Techniques

  • Cognitive Behavioral Techniques:

    • Keep focus on manageable, clearly defined problems.

    • Utilize role-play for stressful situations.

    • Introduce biofeedback techniques through apps or wearables.

ANXIETY NON-PHARMACOLOGIC TREATMENTS

  • Behavioral Therapy Techniques:

    • Modeling

    • Systematic Desensitization

    • Flooding

    • Thought Stopping

  • Cognitive-Behavioral Therapy (CBT):

    • Exposure and Response Prevention specifically, with further details in OCD-related content.

ANXIETY PATIENT EDUCATION

  • Teaching Strategies:

    • Provide verbal/written material on diagnosis, symptoms, etiology, and treatment options.

    • Explain anxiety as a result of dysfunctional appraisal and automatic thinking.

    • Teach behavioral techniques including thought stopping.

    • Role-play coping strategies for anxiety-provoking situations.

    • Encourage journals to track anxiety triggers and strategies utilized, rating anxiety from 1 to 10.

ANXIETY HEALTH PROMOTION

  • Suggestions for Improvement:

    • Prioritize sleep, exercise (aerobic), and reduction of caffeine.

    • Incorporate music, pets, and massage as part of stress management.

ANXIETY MEDICATIONS

  • Review for Pharmacological Management:

    • Key medication classes include:

    • SSRIs (Selective Serotonin Reuptake Inhibitors)

    • SNRIs (Serotonin-Norepinephrine Reuptake Inhibitors)

    • Benzodiazepines

    • Buspirone

    • Tricyclic Antidepressants

    • Utilize Lehne’s Pharmacology for detailed study and ATAT sections in the Psych Workbook for each medication.

GENERALIZED ANXIETY DISORDER (GAD) INTRODUCTION

  • Definition:

    • GAD is one of the most prevalent mental disorders characterized by persistent, excessive, and unrealistic worry about everyday issues such as finances, family, health, and future.

    • Associated with feelings of being overwhelmed.

GAD ETIOLOGY

  • Commonly Associated Factors:

    • Female gender

    • Being unmarried

    • Poor health or chronic medical conditions

    • Low education levels

    • Presence of stressors

    • Genetic predisposition (25% likelihood if first-degree relative has GAD)

    • Environmental factors, including child abuse

    • Substance abuse

GAD DSM-V CRITERIA

  • Diagnostic Criteria (according to the DSM-5):

    • Excessive anxiety and worry for at least six months

    • Difficulty controlling the worry.

    • Association with three or more symptoms for at least six months:

      • Restlessness or feeling keyed up

      • Easily fatigued

      • Difficulty concentrating or mind going blank

      • Irritability

      • Muscle tension

      • Sleep disturbances

    • Resulting distress must significantly impair social and occupational functioning

    • Not attributable to a physical cause

GAD ASSESSMENT

  • Challenges with Diagnosis:

    • Diagnosis can be complex due to common presentation of somatic symptoms rather than psychological symptoms.

  • Symptoms:

    • Common somatic complaints include breathlessness, palpitations, fatigue, headaches, dizziness, and restlessness.

    • Psychological complaints often include vague anxiety, emotional lability, concentration difficulties, and insomnia.

  • Initial Assessment Focus:

    • Assess for behavioral or somatic symptoms.

    • Consider psychosocial stressors, developmental issues, and past medical history (including trauma and substance abuse).

    • Conduct evaluations to rule out organic causes:

    • Thyroid function tests

    • Blood glucose level

    • Echocardiography

    • Toxicology screen.

    • GAD-7 Questionnaire:

    • A screening tool to help identify and monitor patients with GAD.

GAD RULE OUT MEDICAL CAUSES

  • Medical Conditions to Consider:

    • Hyperthyroidism

    • Pheochromocytoma

    • Chronic Obstructive Pulmonary Disease (COPD)

    • Transient Ischemic Attack (TIA)

    • Epilepsy

    • Bipolar disorder

    • Caffeine or stimulant use

GAD INCREASES RISK OF:

  • Complications:

    • Development or worsening of other conditions such as:

      • Depression (often comorbid)

      • Insomnia

      • Drug or alcohol misuse

      • Gastrointestinal problems

      • Social isolation

      • Impaired functioning in work or school

      • Poor quality of life

      • Potential for suicide.

GAD TREATMENT

  • Primary Treatment Approaches:

    • Cognitive Behavioral Therapy and pharmacotherapy are the two main treatments, often utilized together.

    • Cognitive Behavioral Therapy (CBT):

    • Involves psychoeducation, restructuring maladaptive thought patterns, and gradual exposure to anxiety-provoking situations.

    • Pharmacotherapy:

    • Utilizes various medications for treatment.

GAD TREATMENT - Pharmacotherapy

  • Antidepressants:

    • SSRIs and SNRIs are first-line treatments, including:

    • Escitalopram (Lexapro)

    • Duloxetine (Cymbalta)

    • Venlafaxine (Effexor XR)

    • Paroxetine (Paxil).

  • Benzodiazepines:

    • Examples include diazepam and clonazepam for short-term symptom alleviation.

    • Caution advised in patients with a history of substance abuse due to dependency risks.

  • Buspirone:

    • Non-benzodiazepine option, not inducing dependency and with a slower onset (2-3 weeks).

  • Antipsychotics:

    • May benefit patients with associated behavioral issues.

GAD TREATMENT - Medication Management

  • Administration Protocol:

    • All medications need gradual titration and continued use for a minimum of 4 weeks to evaluate efficacy.

    • After symptom stabilization, medications should be taken for at least 12 months before tapering.

  • Monitoring for Adverse Effects:

    • Potential side effects including weight gain, hyperlipidemia, and diabetes must be monitored closely.

GAD TREATMENT - Patient Education

  • Importance of Education:

    • Educating patients on triggers of anxiety is crucial (e.g., caffeine, alcohol, nicotine, managing stress, and optimizing sleep).

  • Complementary and Alternative Remedies:

    • Various options exist, but efficacy is often unproven.

    • Some agents (e.g., Kava) may harm the liver; others (e.g., St. John's Wort) might interact with SSRIs leading to serotonin syndrome.

GAD PROGNOSIS

  • Overall Outlook:

    • Prognosis is often guarded due to factors like medication non-compliance driven by cost and side effects.

    • Relapses are frequent; patients often seek out alternative therapies that may not yield success.

    • Quality of life for affected individuals remains a concern.