Unit 5 1125

UNIT 5

  • Instructor: M. Shackelford MSN, RN

ANXIETY

WHAT IS ANXIETY?

  • Normal response to stress and a common human experience

  • Most diagnosed psychiatric disorder in the U.S.

  • Optimally serves an adaptive function to protect an individual from danger.

  • Becomes a disorder when it interferes with daily functioning.

  • 30% of adults experience anxiety disorders at some point in their lives

STRESS RESPONSE VS. ANXIETY

  • Both involve physiological responses.

  • Stress Response: Proportionate to stressor.

  • Anxiety: Response to stress that may be real or perceived.

  • dry ,mouth, sweating

TYPES OF ANXIETY

Acute Anxiety

  • Precipitated by an imminent loss or change that threatens one’s sense of security.

Chronic Anxiety

  • Develops over time, often starting in childhood.

TOXIC STRESS RESPONSE

  • Biological & Neurological Changes resulting from sustained toxic stress.

  • Alterations in executive functioning.

ANXIETY DISORDERS

  • Combination of heredity and learned response to stress.

  • Genetic factors, enviromental factors,

  • Over 25% of 13-18-year-olds are affected.

  • related anxiety disorders median age of 6, diagnosis median 12

  • Females are twice as likely to be affected than males.

THE ANXIETY CYCLE

  • Triggers: Stressful thoughts such as "What will happen next?" or "I can’t do this."

  • Physiological Responses:

    • Fear

    • Anxiety

    • Worry

    • Dizziness

    • Elevated heart rate

    • GI distress

    • Fast, shallow breathing

    • Dry throat

    • Beginning to sweat

    • Concentration disrupted

  • Fight/Flight Responses:

    • Fight: Anger, frustration, aggression.

    • Flight: Avoidance or alcohol use.

    • Freeze: Unable to respond.

    • Fawn: Trying to please to avoid anxiety.

LEVELS OF ANXIETY

Mild Anxiety

  • Occurs in normal experiences of everyday living.

  • There is an identifiable cause of anxiety.

Moderate Anxiety

  • Occurs when mild anxiety escalates; usually benefits from direction of others.

  • Symptoms:

    • Narrow perceptual field

    • Voice tremors

    • Difficulty concentrating

    • Increased heart & respiratory rates

    • Pacing

Severe Anxiety

  • Functioning is effective; behaviors are automatic.

  • Cannot take directions from others.

  • Symptoms:

    • Greatly reduced perceptual field

    • Feelings of dread or confusion

    • Chest discomfort and diaphoresis

    • Loud, rapid speech

Panic Anxiety

  • Client is unable to process the environment and may lose touch with reality.

  • Symptoms:

    • Unfocused perception of environment

    • Hallucinations or delusions

    • Increased somatic responses

NURSING INTERVENTIONS

  • Help clients identify their anxiety.

  • Anticipate anxiety-provoking situations and help mitigate.

  • Show interest by leaning forward and maintaining eye contact.

  • Ask questions for clarification and encourage problem-solving.

  • Maintain a calm manner and stay with the client.

  • Minimize environmental stimuli and use simple, clear statements.

  • Use a low-pitched voice and attend to physical and safety needs.

  • active listening skills, willingness to help, keep them focused centered

  • STAY WITH YOUR PATIENT …. SAFTY

DEFENSE MECHANISMS

  • Denial

  • Projection

  • Regression

  • Sublimation

COMORBIDITIES

  • Mood disorders like major depressive disorder, bipolar disorder.

  • Obsessive-compulsive personality disorder.

  • Tic disorder, ADHD, oppositional defiant disorder.

  • Schizophrenic spectrum disorders, eating disorders, substance use disorders.

MEDICAL COMORBIDITIES

  • Includes conditions like pulmonary embolism, asthma, stroke, myocardial infarction, cancer, sepsis, chronic pain, IBS, and delirium.

RISK FACTORS

  • Brain chemistry, social influence, lifestyle factors, family background, genetic predisposition.

  • •Trauma or negative life experiences such as adverse childhood experiences

    •Personality trait or temperament, including tendency for shyness or avoidance

    •Family history of mental health disorder

    •History of illness, such as thyroid or cardiac conditions

    •Genetic predisposition

    •Lifestyle, including lack of a healthy diet, poor exercise, and alcohol or substance use

ADVERSE EXPERIENCES (ACES) AND POSITIVE EXPERIENCES (PCES)

  • Childhood experiences can impact future outcomes.

  • Positive experiences can provide protection against adverse experiences.

GENERAL MANIFESTATIONS

  • Feeling apprehensive or nervous, restlessness, irritability, anticipating the worst result.

GENERAL PHYSIOLOGICAL MANIFESTATIONS

  • Increased heart and respiratory rate, sweating, fatigue/exhaustion, difficulty concentrating, GI disturbances, sleep disruptions.

  • The pathophysiology of anxiety, much like that of stress, begins with an understanding of role of the amygdala-centered circuit in the neurobiology of fear and the fear response. When an individual is exposed to fear, the amygdala and the hypothalamus cause changes in the hypothalamic-pituitary-adrenal axis (HPA), which results in hormone release, leading to the survival response.

SPECIFIC ANXIETY DISORDERS

  • Generalized Anxiety Disorder

  • Social Anxiety

  • Panic Disorder

  • Separation Anxiety

  • Phobias

  • Post-Traumatic Stress Disorder (PTSD)

GENERALIZED ANXIETY DISORDER

  • Excessive worry for at least 6 months causing functional impairment.

  • Symptoms may include restlessness, muscle tension, avoidance of stressful activities, procrastination, and sleep disturbances.

SEPARATION ANXIETY

  • Excessive fear/anxiety upon separation from an emotionally attached individual leading to headaches, nausea, and sleep disturbances.

  • triggered by absence

SOCIAL ANXIETY

  • Excessive fear of social or performance situations.

  • Fear of embarrassment with physical manifestations to avoid social situations.

  • triggered by performance

PANIC DISORDER

  • Attacks typically last 15 to 30 minutes.

  • Can cause persistent worries about future attacks; symptoms include palpitations, shortness of breath, choking, nausea, chills/hot flashes, chest pain, and feelings of depersonalization, dying, or insanityflashbacks, .

PHOBIAS

  • Extreme fear of specific objects or situations.

  • Anxiety can occur just from thinking about the feared object.

POST-TRAUMATIC STRESS DISORDER (PTSD)

  • Results from exposure to traumatic events leading to long-term anxiety, detachment, and other manifestations.

  • Symptoms include intrusive thoughts, nightmares, anger, anxiety, and avoidance behaviors.

NURSING INTERVENTIONS FOR PTSD

  • Establish a therapeutic relationship; create a safe environment.

  • Use multiple strategies to decrease anxiety and assess for suicidal ideations as needed.

OBSESSIVE-COMPULSIVE DISORDERS

  • Not classified as anxiety disorders but have similar effects.

TYPES OF OBSESSIVE-COMPULSIVE DISORDERS

  • Obsessive-Compulsive Disorder (OCD)

  • Hoarding Disorder

  • Body Dysmorphic Disorder

OBSESSIVE-COMPULSIVE DISORDER (OCD)

  • Characterized by intrusive thoughts and compulsive behaviors to relieve anxiety.

  • rituals used to temporarily relieve anxiety

  • time - consuming→ results in impaired social and occupational functioning

HOARDING DISORDER

  • Difficulty parting with possessions, leading to stress and functional impairments.

  • Leads to an UNSAFE LIVING ENVIRONMENT

BODY DYSMORPHIC DISORDER

  • Preoccupation with perceived flaws or defects in physical appearance leading to social and occupational impairment.

  • mirror checking, excessive grooming, skin picking, seeking reassurance about looks, possible eating disorder

STANDARDIZED SCREENING TOOLS

  • Hamilton Rating Scale for Anxiety

  • Fear Questionnaire

  • Panic Disorder Severity Scale

  • Yale-Brown Obsessive Compulsive Scale

  • Hoarding Scale (self-report)

THERAPIES

  • Cognitive Behavioral Therapy (CBT) - a widely used therapeutic approach that focuses on identifying and changing negative thought patterns and behaviors associated with obsessive-compulsive disorder (OCD) and hoarding.

  • Behavioral Therapy- teach clients ways to decrease anxiety or avoidant behavior and allow and opportunities to practice techniques

  • Relaxation Training- control pain, tension, anxiety

  • Systematic Desensitization

  • Prolonged Exposure Therapy for PTSD

  • EMDR- eye movement desensitization and reprocessing, a psychotherapy technique that helps individuals process and integrate traumatic memories through guided eye movements.

  • no EMDR for suicidal, psychosis, dissociative disorders, detached retina/ glaucoma

  • Group or Family Therapy

  • Biofeedback

CLIENT EDUCATION

  • Monitor for anxiety manifestations and notifying the provider if symptoms worsen.

  • Encourage lifestyle management.

  • Advise clients not to adjust medication dosages without consulting their provider.

PSYCHOPHARMACOLOGY

ANTIDEPRESSANTS

  • Selective Serotonin Reuptake Inhibitors (SSRIs):

    • Citalopram

    • Fluoxetine

    • Sertraline

    • Paroxetine

    • ( - INE ) has something to do with SEROTONIN

    • mechanism of action affects serotonin by selectively blocking the reuptake on presynaptic receptors.

    • First line of treatment for anxiety and OCDs

    • Paroxetine used commonly in PTSD

    • may experience nausea, agitation, and sexual dysfunction.

    • SSRIs may take up to four to six weeks

  • Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs):

    • Venlafaxine

    • Duloxetine

    • mechanism of action affects serotonin and norepinephrine by selectively blocking the reuptake of presynaptic receptors.

    • may experience nausea, agitation, and appetite suppression

  • Tricyclics:

    • Imipramine

    • Amitriptyline

    • mechanism of action affects serotonin and norepinephrine by blocking their reuptake in presynaptic receptors.

    • TCAs block cholinergic receptors resulting in anticholinergic effects like dry mouth and constipation.

    • Over time, clients may develop a tolerance to the anticholinergic effects of TCAs. 

    • risk for orthostatic hypotension with TCAs.

    • May take up to two to four weeks

ANXIOLYTICS

  • Benzodiazepines:

    • Alprazolam

    • Clonazepam

    • Diazepam

    • ( -am ) = Benzo ( quick fix )

    • most prescribed medications to treat anxiety.

    • The mechanism of action for benzodiazepines is to regulate the function of the neurotransmitter GABA.

    • Benzodiazepines bind to GABA receptor sites, causing an influx of chloride to enter the neuron, producing a major inhibitory effect.

    • A cascade effect occurs when benzodiazepines are introduced into the brain, causing a large amount of dopamine to be released in the limbic system. This effect greatly increases the potential for physical dependence on benzodiazepines.

    • may cause drowsiness. educate patient's not to drive, etc.

    • antagonist for benzos (in case of OD): flumazenil. **Flumazenil may induce seizures in clients who have a history of seizure disorders or who are taking tricyclic antidepressants

  • Non-benzodiazepines:

    • Buspirone

    • ( long term med )

    • Buspirone is a partial serotonin receptor agonist and a weak dopamine receptor antagonist. It does not affect GABA receptors. The clinical effects of buspirone are not experienced for a few weeks and are thought to be related to the adaptive response of the brain. Buspirone is commonly prescribed to treat chronic anxiety.

OTHER DRUGS

  • Anticonvulsants:

    • Gabapentin

    • Pregabalin

  • Specific to PTSD:

    • Prazosin

    • Propranolol

    • Prazosin, a centrally-acting alpha agonist, can decrease manifestations of hypervigilance and insomnia.

    • Propranolol, a beta-adrenergic blocker, decreases elevated vital signs and manifestations of anxiety, panic, hypervigilance, and insomnia

CLIENT OUTCOMES

  • Evaluate if the client remains free from injury or harm.

  • Assess if clinical manifestations of anxiety have reduced over time.

  • Reassess the client following interventions to determine effectiveness.

  • Consider if the client is able to use coping strategies as needed.