Week 5: Anxiety and Anxiety Disorders

Chapter 14: Anxiety and Anxiety Disorders

Introduction to Anxiety

  • Definition of Anxiety:

    • A vague feeling of dread or apprehension.

    • Response to external or internal stimuli.

  • Symptoms of Anxiety:

    • Behavioral, emotional, cognitive, and physical symptoms.

  • Distinction from Fear:

    • Fear is a response to a clearly identifiable external stimulus.

  • Normal Anxiety:

    • Appropriate to the situation.

    • Dissipates when the situation is resolved.

  • Anxiety Disorders:

    • Characterized by excessive anxiety.

    • Includes panic without reason, unwarranted fear, and overwhelming worry.

  • Impact of Anxiety Disorders:

    • Significant distress over time.

    • Impairs daily routines, social lives, and occupational functioning.

Anxiety as a Response to Stress

  • Stress:

    • Defined as the wear and tear caused by life situations.

    • Varies from person to person.

    • Examples of stressors include public speaking, marriage, new jobs.

  • Hans Selye's General Adaptation Syndrome:

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

    • Stages of Reaction to Stress:

      • Alarm reaction.

      • Resistance stage.

      • Exhaustion stage.

Alarm Reaction Stage

  • Body's Response to Stress:

    • Messages are sent from the hypothalamus to glands and organs.

    • Adrenal glands release adrenaline and norepinephrine.

    • The liver reconverts glycogen stores to glucose.

    • Prepares body for potential defense needs with increased fuel and food supply.

Resistance Stage

  • Physiological Changes:

    • Digestive system reduces function.

    • Blood shunted to areas needed for defense.

    • Increased activity of lungs and heart.

    • More air intake and faster heartbeats.

    • Circulation of oxygenated and nourished blood to muscles to adapt to stress.

    • Relaxation of body responses if stress is managed.

Exhaustion Stage

  • Negative Response to Anxiety and Stress:

    • Depletion of body stores occurs.

    • Continual arousal of physiological responses leads to little reserve capacity.

Autonomic Nervous System Responses

  • Autonomic Nervous System:

    • Involuntary activities vital for self-preservation.

    • Sympathetic Nervous System:

      • Activates the body in response to danger (fight or flight).

      • Adrenal glands release adrenaline, increasing heart rate and blood pressure.

    • Parasympathetic Nervous System:

      • Reverses the process to return the body to normal conditions.

Physiological Responses to Anxiety

  • Responses Include:

    • Difficulty with logical thought.

    • Increased agitation in motor activity.

    • Elevated vital signs (heart rate, blood pressure).

    • Adaptive behaviors to reduce discomfort, such as relaxation and imagery techniques.

    • Maladaptive Behaviors: May manifest as tension headaches, pain syndromes, and other stress-related symptoms.

Levels of Anxiety

  • Four Levels of Anxiety:

    • Mild Anxiety (Level 1):

      • Sensation of something different; increased sensory stimulation.

      • Motivates change and goal-directed activity.

    • Moderate Anxiety (Level 2):

      • Disturbing feelings, nervousness, or agitation.

      • Difficulty in independent concentration.

    • Severe Anxiety (Level 3):

      • Trouble thinking and reasoning with increased muscle tension and vital signs.

      • Focus on self-defense.

    • Panic Anxiety (Level 4):

      • Characterized by fight, flight, or freeze responses with an adrenaline surge.

Table 14.1: Levels of Anxiety

  • Anxiety Level

    • Mild:

      • Psychological Responses: Wide perceptual field, sharpened senses, increased motivation.

      • Physiological Responses: Restlessness, fidgeting, GI "butterflies."

    • Moderate:

      • Psychological Responses: Perceptual field narrowed to immediate task, selectively attentive.

      • Physiological Responses: Irritability, muscle tension, high voice pitch.

    • Severe:

      • Psychological Responses: Perceptual field reduced to one detail, ineffective problem-solving.

      • Physiological Responses: Nausea, trembling, rigid stance.

    • Panic:

      • Psychological Responses: Inability to process environmental stimuli, distorted perceptions, possible delusions and hallucination.

      • Physiological Responses: Dilated pupils, increased blood pressure and pulse, may bolt and run or be immobile.

Interventions for Clients with Anxiety

  • Assessing Anxiety Level:

    • Determines effective nursing actions.

    • For mild anxiety, no direct intervention is needed; effective teaching should suffice.

  • For Moderate Anxiety:

    • Ensure the client follows the information presented; use short, simple sentences.

  • Management for Severe and Panic Anxiety:

    • For severe anxiety, lower the anxiety level before proceeding, remain with the client, and speak calmly.

    • For panic anxiety, prioritize safety by moving to a quiet environment.

  • If the client is in a panic, we have the right to meditate to ease their panic.

Stress-Related Illnesses

  • A broad spectrum of illnesses arises from chronic stress, including:

    • Eating disorders such as anorexia nervosa and bulimia.

    • Post-Traumatic Stress Disorder (PTSD) from traumatic stressors.

    • Somatic symptom disorders.

    • Exacerbation of medical conditions such as hypertension and ulcerative colitis.

Overview of Anxiety Disorders

  • Definition:

    • Diagnosed when anxiety becomes chronic and pervasive, resulting in maladaptive behaviors and emotional disability.

  • Types of Anxiety Disorders:

    • Agoraphobia: Fear of being in situations where escape might be difficult.

    • Panic Disorder: Most common; characterized by panic attacks.

    • Specific Phobia: Intense, irrational fear of a specific object or situation.

    • Social Anxiety Disorder: Fear of social situations.

    • Generalized Anxiety Disorder (GAD): Excessive, uncontrollable worry (diagnosed when it results over 6 months).

Assessment Data for Anxiety Disorders

  • Common Indicators:

    • Decreased attention span, restlessness, irritability, feelings of discomfort or helplessness, hyperactivity, and perceptual field deficits.

      • May see these be laced in with symptoms of psychosis or delusion when mixed with a diagnosis such as schizophrenia or other mental disorders.

  • Expected Outcomes:

    • Immediate: Free from injury; discuss feelings within 24 to 48 hours.

    • Stabilization: Demonstrate relaxation techniques; manage anxiety response to stress effectively.

    • Community: Remain free from anxiety attacks, maintain a healthy anxiety response to stress.

      • Learn about what is in your toolbox.

Medications for Anxiety Disorders

  • Benzodiazepines:

    • Examples: Diazepam (Valium), Alprazolam (Xanax)

    • Side Effects: Dizziness, sedation; high potential for abuse.

  • Nonbenzodiazepines:

    • Examples: Buspirone (BuSpar), Meprobamate (Miltown).

  • SSRIs and Other Medications:

    • Examples: Fluoxetine (Prozac), Paroxetine (Paxil) for treating panic disorder, GAD, and social phobia.

    • First line of treatment, as it has the least amount of side effects.

Related Disorders

  • Anxiety Disorder Due to Another Medical Condition:

    • Symptoms stem from physiological issues, e.g., endocrine dysfunction.

  • Substance/Medication-Induced Anxiety Disorder:

    • Caused directly by drug misuse or exposure to toxins; requires therapy and anxiety management techniques alongside medication.

  • Separation Anxiety Disorder:

    • Excessive anxiety over separation from attachment figures, diagnosed before age 18.

Etiology of Anxiety Disorders

  • Should always make note of whether our patients have had trauma/what type/to what extent.

  • Biologic Theories - Genetics:

    • Anxiety has an inherited component; higher rates of anxiety in first-degree relatives.

  • High Heritability:

    • Greater than 0.6; suggests genetic influences dominate.

  • Moderate Heritability:

    • Ranging from 0.3 to 0.5; indicates a balance of genetic and non-genetic factors.

  • Low Heritability:

    • Less than 0.3; indicates negligible genetics as a primary cause.

Neurochemical Theories of Anxiety Disorders

  • GABA:

    • Inhibitory neurotransmitter, dysfunctional in anxiety disorders.

  • Norepinephrine:

    • Suspected excess in panic disorder, generalized anxiety disorder, and PTSD.

  • Serotonin:

    • Affects anxiety, aggression, and mood; implicated in OCD and GAD.

Psychodynamic Theories

  • Freud's Perspective on Anxiety:

    • Anxiety is an innate stimulus for behavior; may lead to defense mechanisms that inhibit emotional growth.

Behavioral Theory of Anxiety

  • Anxiety as a Learned Behavior:

    • Fear can be learned and unlearned through experiences, behavior modification can help.

Cultural Considerations in Anxiety Disorders

  • Cultural Differences:

    • Various cultures may express anxiety through somatic symptoms.

    • Cultural humility in nursing focuses on understanding these differences (avoid stereotypes).

Treatment for Anxiety Disorders

  • Combination of Medication and Therapy:

    • Produces better results than either alone; includes CBT for anxiety management.

  • Medications:

    • SSRIs, benzodiazepines, and others, as listed in Table 14.3.

  • Therapeutic Techniques:

    • Includes decatastrophizing and assertiveness training.

Age-Related Considerations in Anxiety Disorders

  • Children:

    • Issues with selective mutism and separation anxiety disorder may persist into adulthood.

  • Older Adults:

    • Anxiety is often associated with depression and dementia; SSRIs are preferred for treatment.

Community-Based Care for Anxiety Disorders

  • Treatment Settings:

    • Many clients are encountered in community settings rather than inpatient settings.

    • Knowledge of community resources facilitates appropriate referrals.

Mental Health Promotion

  • Anxiety as a Warning Sign:

    • Indicates ineffective stress management; provides an opportunity for necessary change.

Tips for Managing Stress

  • Positive Attitude:

    • Embrace relaxation techniques, regular exercise, and realistic goal setting to manage stress effectively.

Panic Disorder and Panic Attacks

  • Panic Disorder:

    • Characterized by episodes lasting 15 to 30 minutes with intense anxiety symptoms.

  • Diagnostic Criteria for Panic Disorder:

    • Recurrent panic attacks without environmental triggers; persistent concern about attacks; significant behavioral changes.

  • Symptoms: palpitations, sweating, tremors, SOB, chest pain, nausea, dizziness, chills, or hot flashes.

  • Panic Attacks: Early trauma may contribute to this and should be addressed.

    • Onset: peaks in late adolescence to mid-30s

Treatment for Panic Disorder

  • Cognitive-Behavioral Therapy (CBT):

    • Includes deep breathing and relaxation techniques; medications can include SSRIs and antihypertensives.

    • Change the way a person thinks and channel positive thoughts.

  • Safety and Comfort:

    • Providing a safe environment, remaining with the client during panic attacks, and using calm communication.

Evaluation in the Management of Anxiety Disorders

  • Ongoing Assessment:

    • Individualized evaluations for each client; perception of treatment success is essential.

  • Hamilton Rating Scale for Anxiety (used universally).

    • History of panic attacks and their impact

    • General appearance and motor behavior

    • Mood and affect

    • Thought processes and content

    • Sensorium and intellectual processes

    • Judgement and insight

    • Self-concept

    • Roles and relationships

    • Physiological and self-care concerns

Social Phobia (Social Anxiety Disorder)

  • Definition: An illogical, intense, and persistent fear of a specific object/social situation. People usually recognize that it is irrational.

  • Diagnosis: Made when phobic behavior significantly interferes with life.

  • Symptoms and Common Triggers:

    • Severe anxiety in social situations, fear of judgment; common triggers include public speaking and social engagements.

Conclusion

  • Anxiety disorders encompass a wide range of symptoms that impact individuals across varying stages of life. Understanding causes, symptoms, and management techniques is crucial for effective treatment and support.