Anxiety Disorders

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Anxiety Disorders
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ANXIETY DISORDERS

• AnxietyVague,
• subjective non specific feeling.
• uneasiness, apprehension
• tension,feeling of dread or impending doom
• Causes- result of threat to ones Biologic,
  Physiologic and Social Integrity- external
  influences

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Types of Anxiety

• Signal Anxiety- (Phobic Disorders)
• Precipitant is identified
• A learned anxiety response-results from
  situations successfully repressed or coped with
  using another defense mechanism

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Trait anxiety

• A function of Personality structure
• Link with developmental process/events
• May be linked to unresolved conflict/confusion
  (Anxiety Diathesis)a pre-disposition to anxiety
  when exposed to stressor.
• E.g.. One had a chronically ill mother and is
  overprotective w/own children.

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State Anxiety

• Develops in conflict or stressful situations
• Experiences limited control
• Anxiety occurs before the situation arises
• E.g.. Woman who avoids making appt w/PMD after
  finding breast mass and has a strong family hx.
  Of cancer.

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Free Floating Anxiety

• Pervasive sense of dread or doom
• Cannot be attached to any idea or event
• May result in panic state if stressors exceed the
  individuals ability to cope.

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Levels of Anxiety

• Hildegard Peplau Interpersonal Relations in
  Nursing 1952 identified Four stages of anxiety
  on a continuum
• Mild
• Moderate
• Severe Panic
• Panic

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Behavioral Physiologic changes in Mild Anxiety

• Perceptual field widens
• Î awareness motivation
• Î problem solving learning
• Irritable
• Related client Needs

• Restlessness
• butterflies in stomach
• Î sleep disturbance
• More sensitive to noise

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Behavioral Physiologic changes Moderate Anxiety

• Immediate task oriented
• Attentive to immediate task
• Difficulty w/concentration,but can be redirected

• V/S normal increased
• Frequent urination
• Dry mouth/muscle tension
• Î rate of speech
• diaphoretic

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Behavioral Physiologic changes in Severe Anxiety

• Narrowed perceptual field-one detail
• Difficulty completing task or solving problems
• Cannot learn effectively
• Feelings of dread/doom
• Crying
• Ritualistic behaviors ie. Rocking

• Headache/nauseavomiting
• Vertigo
• Pale
• Tachycardia
• C/o chest pain
• Rigid stance

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Behavioral Physiologic changes in Panic level
anxiety

• Unable to process environmental stimuli
• Distorted perceptions
• Can only focus on self
• Risk for self harm
• Unable to communicate
• Irrational thoughts/behaviors
• Possible delusions/hallucinations

• Can run away from scene or
• Can be immobilized mute
• Dilated pupils
• Î B/P, P, R
• Flight,fight or freeze reaction

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Etiological Theories/Anxiety

• Biologic Model
• Hans Selye- expanded the idea that endocrine
  system and CNS (hypothalamus and Pituitary gland
  ) have reciprocal relationships
• Studies of the neuropharmacology of the Autonomic
  Nervous System (ANS) re regulation of
  Cardiovascular/GI/Motor systems was shown
  responsive to stimuli
• RXs target seratonin, noradrenergic,
  y-amino-butyric acid(GABA)

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Psychodynamic Model

• Concept views Anxiety as a warning to the ego
• Three types Anxiety identified
• REALITY Anxiety(painful emotional experience
  resulting from perception of danger in external
  world)
• MORAL Anxiety (THE Egos experience of Guilt and
  Shame)
• NEUROTIC Anxiety (perception of threat according
  to ones instincts)
• Neurotic sxs develop to defend against anxiety

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Interpersonal /Social Psychology Models/Anxiety

• Anxiety is the response to external environment
• SullivanAnxiety is the first great educative
  experience in living
• Symptoms were response to expectations/insecuritie
  s/frustrations/conflicts between person and
  Primary Groups i.e..family, colleagues, social
  associates.
• Emphasis on early development

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Behavioral Model/Anxiety

• Based on Learning theory- etiology of sxs based
  on generalization of an earlier traumatic
  experience to a benign setting or object.
• Links past experiences with present responses
  anxiety occurs when a signal predicts a
  painful or feared event
• May be linked to PTSD

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Epidemiology of Anxiety Disorders

• Anxiety D/Os ---6 8 of population
• More prevalent in women 22-44 y/o in
  separated/divorced group
• Except for OCDs and Social Phobias anxiety
  greater in women
• Clients w/major Depression 18.8 inc.risk for
  panic d/o and 15/3 risk for agoraphobia
• 10-12 of general population have simple phobias

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Epidemiology of Anxiety Disorders in the Older
Adult

• 3.5 10 of elders suffer from Anxiety disorders
• 10-15 of Women 65 y/o seek help from MD (Hegel,
  et.al 2002)
• RISK factors female urban living
• hx. Of worry or ruminationpoor physical health
  low socioeconomic status stressful life
  eventsdepression alcoholism
• GAD most common anxiety D/O in the elderly
• C/b worry- co-exist w/depression.

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Behavioral manifestations of Panic attacks

• PANIC ATTACK-sudden onset intense
  apprehension-fearfulness-terror assoc w/impending
  doom-lasts 15-30 minutes
• 4 or more sxs i.e..palpitations, sweating,
  trembling SOB,choking,smothering sensation

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Behavioral manifestations of Phobias

• PHOBIAS avoidance of object or situation
• Significant distress or impairment of daily
  routines,occupation or social functioning.
• Fear recognized as excessive or unreasonable

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Post Traumatic Stress Disorder (PTSD)

• C/b re-experiencing an extremely traumatic
  event(begins within 3 months to years after event
  lasting months or years
• Person avoids the stimuli associated with the
  event,
• numbing of responsiveness,increased arousal

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PTSD---characteristics

• Intense fear /helplessness/horror upon exposure
• Dreams,flashbacks,
• Physical/psychological distress over reminders of
  the event
• Avoids memory provoking stimuli
• Feeling detached or estranged from others
• Increased arousal (irritability,angry
  outburst,sleep problems,hypervigilance,exaggerated
  startle response)

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PTSD interventions

• Promote desensitization through gradual exposure
  to event or situation similar to the event
• Teach relaxation techniques
• Provide individual therapy to address loss of
  control issues
• Encourage use of support groups
• Encourage use of hypnotherapy

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Generalized Anxiety Disorder

• C/b at least 6 months of persistent, excessive
  worry and anxiety.
• Uncontrollable worrying
• Significant distress w/impaired social or
  occupational functioning
• 3 of the followingrestlessness, fatigues
  easily,difficulty w/concentration, thought
  blocking,irritability, muscle tension sleep
  disturbance.

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Interventions

• Attend to physical symptoms
• Assist client to identify thoughts that arouse
  the anxiety their bases
• Assist client to change unrealistic thoughts to
  more realistic thoughts
• Use cognitive re-structuring
• Administer anti-anxiety medications as prescribed

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Obsessive Compulsive Disorder

• Obsessions ( thoughts, impulses or images) which
  cause marked anxiety or Compulsions(repetitive
  behaviors or mental acts)
• Recurrent, persistent, unwanted thoughts impulses
  or images
• Attempts to ignore,suppress,or neutralizes
  obsessions with compulsions are mostly
  ineffective.

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OCD interventions

• Identify the situation that precipitates the
  behavior
• Do not interrupt compulsive behaviors
• Allow time for compulsive rituals
• Provide safety related to behaviors
• Provide schedule to distract behaviors
• Set limits on rituals that may interfere with
  client well-being
• Establish written contract-decrease frequency of
  compulsive behaviors

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Developmental considerations

• Child
• Adolescent
• Adult
• Elder

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Cultural Considerations for Anxiety disorders in

• Hispanic
• African American
• Asian
• European- American
• Middle Eastern

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Scenario for a Client with Anxiety

• Gina a 42 year-old female comes to the
  out-patient clinic with complaints of increasing
  restlessness, insomnia, difficulty concentrating,
  fatigue, and frequent tearfulness. She is widowed
  for one year, and is a single parent to three
  children. Recently, there have been several
  layoffs at her job and she is fearful that she is
  next in line. During the interview she is
  wringing her hands and rubbing her face
  repeatedly while rocking in her chair.
• 1. What further history would you obtain
• 2. Prioritize Two problems that require Nursing
  Interventions
• 3 Identify outcomes Interventions
• 4. What medication would you expect to be ordered
  and why?

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Nursing Care Plan Anxiety

• Assessment data
• Appearance,Behavior,Conversation i.e.
• Wringing hands,decreased communication,restlessnes
  s, irritability,pacing,decreased attn, poor
  impulse control
• Identify stressors- intra,inter, extrapersonal
• Physiological s/sx
• Safety

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Goals/expected outcomes

• Short term
• The client will be free of injury
• Discuss feelings of dread or anxiety
• Respond to relaxation techniques
• Demonstrate ability to perform relaxation

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Implementation anxiety

• Remain with client at all times if level is
  severe or panic(safety important)
• Remove client to Quiet area( client is not able
  to deal with excessive stimuli)
• Remain calm upon approaching client(client will
  feel more secure if you are in control of
  situation)
• Use short simple clear statements(impaired
  ability to deal with abstractions/complexities)
• Use PRN meds as indicated

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Nursing interventions

• Educate client re use of caffeine, nicotine
  etc.(prevents/minimizes cardiovascular responses
  i.e. Inc heart rate and jitteriness)
• Provide instruction regarding anxiety reduction
  stretagies
• Progression relaxation techniques
• Listening to smoothing music or relaxation tapes

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• The nurse is working with the family of a client
  with Obsessive Compulsive D/O.Which of the
  following should the nurse incorporate in the
  teaching plan?
• A.) the thoughts images and impulses are
  voluntary
• B.) the family should pay immediate attention to
  symptoms
• C.) the thoughts, images and impulses worsen the
  stress
• D.) OCD is a chronic disorder not responsive to
  treatment

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• A client displays isolation, bizarre behaviors,
  unsafe actions and poor hygiene. Which will be
  the first priority in the nursing care plan?
• A.) Safety
• B.)Hygiene
• C.)Isolation
• D.) Bizarre behaviors

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• The nurse would analyze the symptoms of muscle
  rigidity, GI upset, rapid speech,and need to
  urinate as which level of anxiety?
• A.) Mild
• B.) Moderate
• C.) Severe
• D.) Panic

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• A client has recently been involved in assisting
  with the clean-up from a flood that washed away
  many homes in his area and caused loss of
  life.Which of these interventions would assist
  the client in dealing with the traumatic
  experience.
• A. Provide the opportunity to talk about the
  experience.
• B. Encourage the client to leave the area in
  order to forget the experience.
• C. Suggest admission to a mental health facility.
• D. Arrange for a minister to speak with the
  client.

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• Appropriate discharge criteria for a client with
  chronic anxiety disorder is the client will---
• A.) experience no more anxiety
• B.) suppress the anxiety symptoms and focus on
  the future
• C.) Identify situations and events that trigger
  anxiety
• D.) recognize the need to take medications for
  the rest of his/her life to control anxiety

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• The nurse is working with a client with chronic
  anxiety. The goal is that the client will
  identify early warning symptoms of anxiety.The
  nurse would analyze the client as moving towards
  this goal when the client
• A.) begins to connect panic symptoms with
  thoughts about a recent break-up in a
  relationship.
• B.) is free of anxiety for one week
• C.)practices relaxation techniques daily and when
  anxiety increases
• D.)recognizes that others also experience anxiety
  in varying situations

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• Which most characteristic behavior of a panic
  response is the nurse likely to note?
• Goal directed behavior aimed at a flight from
  apparent threat.
• Automati8c behavior with poor judgment.
• A severity of reaction that is not related to the
  severity of the threat to self-esteem.
• A delayed reaction in perceiving the danger.

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• A client is to receive medication therapy for an
  anxiety disorder. To reduce the risk of
  dependence and problems related with withdrawal,
  which of the following agents would the nurse
  most likely anticipate as being prescribed?
  (select all that apply)
• Paroxetine (Paxil)
• Sertaline (Zoloft)
• Lorazepam (Ativan)
• Venlafaxine (Effexor)
• Clonazepam (Klonopin)

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• The nurse assesses a client with a diagnosis of
  Generalized Anxiety disorder for which of the
  following symptoms?
• Fear and avoidance of specific situations or
  places.
• Persistent obsessive thoughts
• Re-experience of feelings associated with
  traumatic events
• Unrealistic worry about a number of events in
  ones life.

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• A 4 year-old girl who is a victim of a bomb blast
  that demolished the building which housed her
  daycare constantly builds block houses and blows
  them up. She also has nightmares frequently.
  Which one of the following diagnoses is
  appropriate for the nurse to make regarding this
  child?
• Post-trauma response related to terrorist attack
  as evidenced by destructive behaviors and sleep
  disturbance.
• Explosive disorder related to dysfunctional
  personality as evidenced by destructive
  behaviors.
• Sleep disturbance related to emotional trauma as
  evidenced by nightmares.
• Ineffective individual coping related to internal
  stressors as evidenced by destructive behaviors
  and nightmares.

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• .When planning discharge for a client with
  chronic anxiety the nurse directs the goal of
  promoting a safe environment at home. The most
  appropriate maintenance goal should focus on
  which of the following
• A. Continues contract with a crisis counselor
• B. Identifying anxiety producing situations
• C. Ignoring feelings of anxiety
• D. Eliminating all anxiety from daily situations

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• A client with OCD is admitted to the psychiatric
  unit for hand washing rituals. The day after
  admission she is scheduled for lab tests. To
  assure that he client is there on time, the nurse
  should
• A. Remind the client several times of her
  appointment.
• B. Limit the number of hand washings
• C. Tell her it is her responsibility to be there
  on time
• D.Provide ample time for her to complete her
  rituals.

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• A client admitted for ritualistic behaviors is
  constipated and dehydrated. Which nursing
  intervention would this client most likely comply
  with?
• A. Drinking Ensure between meals
• B. Drinking extra fluids with meals
• C. Drinking 8 oz. Of water every hour between
  meals
• D. Drinking adequate amounts of fluid during the
  day

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• A woman comes into the emergency room in a severe
  state of anxiety following a car accident. The
  most appropriate nursing intervention is to
• A. Remain with the client
• B. Put the client in a quiet room
• C. Teach the client deep breathing
• D. Encourage the client to talk about her
  feelings and concerns

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• A client is unwilling to go out of the house for
  fear of doing something crazy in public. As a
  result the client remains homebound except when
  accompanied outside by the spouse.
• Based on this data the nurse determines that the
  client is experiencing
• A. Social phobia
• B. Agoraphobia
• C. Claustrophobia
• D. Hypochondrias is

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• A client is admitted to a psych unit after having
  many test for acute blindness for which there is
  no organic cause. The nurse learns the client
  became blind after witnessing a hit and run
  accident, when a family of three was killed. The
  nurse suspects the client may be experiencing
• Psychosis
• Conversion Disorder
• Dissociative Disorder
• Repression

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Somatoform Disorders

• Three central features of Somatoform Disorders
• Physical complaints without organic basis
• Psychological factors and conflicts seem
  important in initiating, exacerbating, and
  maintaining the symptoms
• Symptoms or magnified health concerns are not
  under conscious control(Guggenheim2000)

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Five Somatoform disorders

• Somatization disorder
• C/b multiple recurrent physical complaints over
  many years
• No organic etiology for these complaints
• Begins by age 30
• Pain, GI, sexual, pseudoneurologic symptoms
  impaired coordination or balance,paralysis or
  localized weakness,difficulty swallowing,
  aphonia, urinary retention,hallucinations, loss
  of touch or pain sensation,double
  vision,amnesia,sensory losses,loss of
  consciousness (APA 2000 DSM IV-TR)

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Interventions for somatization

• Be aware of own responses
• Rule out organic basis for complaints
• Focus on anxiety reduction, mot physical symptoms
• Minimize secondary gain(I.e. increased attention
  and decreased responsibilities)

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Conversion Disorder

• Unexplained, sudden deficits
• Sensory or Motor related function e.g..person
  suddenly is blind or paralyzed
• Always associated with Psychological stressors
• Client has an attitude of la belle indifference
  lack of concern or distress

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Intervention conversion d/o

• Focus on anxiety reduction, not physical symptoms
• Use matter-of-fact approach
• Encourage client to discuss conflict
• Minimize secondary gains
• Provide diversionary activities
• Encourage expression of feelings

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Pain Disorder

• C/b physical symptom of pain-one or more anatomic
  sites
• May occur with a General medical condition
• Pain not relieved by analgesics
• Onset,severity, exacerbation and maintenance
  affected by psychological stressors

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Pain d/o interventions

• Pain management
• Encourage participation in activities
• Provide distractions

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Hypochondriasis

• Client is preoccupied with fear that he/she has
  or will get a serious disease
• History of seeing many doctors
• Misinterpretation of bodily sensations or
  functions despite medical evaluations and
  reassurance
• Preoccupation with symptoms is not as intense or
  distorted as in delusional disorder
• Significant distress/impairment in function
• Dependent behaviors/desires,demands attention

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Hypochondriasis interventions

• Rule out presence of actual disease
• Focus on anxiety, not physical symptoms
• Provide diversionary activities
• Avoid negative responses to client
  demands/conference with staff
• Provide client with correct information

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Body Dysmorphic Disorder

• Preoccupation with imagined or exaggerated
  defects in physical appearance
• Causes clinically significant stressor impairment
  in social or occupational function person may
  undergo repeated plastic surgeries for nose
  repair or to change face etc.

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Dissociative Disorders

• DISSOCIATIVE AMNESIA
• One or more episodes of inability to recall
  personal information
• Information is usually of a traumatic or
  stressful nature
• Not due to effects of substance abuse

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Dissociative Fugue

• C/b sudden unexpected travel away from home or
  work
• Unable to recall past(or where on has been)
• Confused about personal identity/ or assumes new
  identity

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Dissociative Identity Disorder

• Individual demonstrates two or more distinct
  identities or personality states
• Each personality is distinct
• At least two of these personality states take
  control of the individuals behavior.
• Unable to recall extensive personal information